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The journal of mental science.

London : Longman, Green, Longman & Roberts, 1859-1962.

http://hdl.handle.net/2027/nj p.32101074924471

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

THE JOURNAL

1 1 i

MENTAL SCIENCE.

EDITORS:

John R. Lord, M.B. Lewis C. Bruce, M.D.

Thomas Drapes, M.B.

Assistant Editors:

Henry Devine, M.D. G. Douglas McRae, M.D.

VOL. LXI.

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCXV.

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PRINCETON UNIVERSITY

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" In adopting our title of the Journal of Mental Science, published by authority
of the Medico-Psychological Association, we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the term
mental physiology or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro- **
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid ; for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we
admit that metaphysics may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity,
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth ; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to a certain extent, attains immediate practical results of the greatest utility
to the welfare of mankind ; we therefore maintain that our Journal is not inaptly
called the Journal of Mental Science, although the science may only attempt to
deal with sociological and medical inquiries, relating either to the preservation of
the health of the mind or to the amelioration or cure of its diseases; and although
not soaring to the height of abstruse metaphysics, we only aim at such meta¬
physical knowledge as may be available to our purposes, as the mechanician uses
the formularies of mathematics. This is our view of the kind of mental science
which physicians engaged in the grave responsibility of caring for the mental
health of their fellow-men may, in all modesty, pretend to cultivate; and while
we cannot doubt that all additions to our certain knowledge in the speculative
department of the science will be great gain, the necessities of duty and of danger
must ever compel us to pursue that knowledge which is to be obtained in the
practical departments of science with the earnestness of real workmen. The cap¬
tain of a ship would be none the worse for being well acquainted with the highei
branches of astronomical science, but it is the practical part of that science as it
is applicable to navigation which he is compelled to study.”— Sir J. C. Ducknill,
M.D., F.K.S.

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PRINCETON UNIVERSITY

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS. 1914-15.

president. —DAVID GEORGE THOMSON, M.D.

PRESIDENT ELECT.— JOHN KEAY, M.D.
ex-president.— JAMES CHAMBERS, M.A., M.D.
treasurer.— H. HATES NEWINGTON, F.R.C.P.

f JOHN R. LORD, M.B.

EDITORS op journal. < LEWIS C. BRUCE, M.D., F.R.C.P.

I T. DRAPES, M.B.

DIV18IONAL 8ECHETAUY POH SOUTH -EASTERN DIVISION,

J. NOEL SERGEANT, M.B.
divisional secretary for south-western division.

JAMES V. BLACIIFORD, M.D.

DIVISIONAL SECRETARY FOR NORTHBRN AND MIDLAND DIVISION.

T. S. ADAIR, M.D.

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION.

ROBT. B. CAMPBELL, M.D., F.R.C.P.

DIVISIONAL SECRETARY FOR IRISH DIVISION.

RICHARD R. LKEPER, F.R.C.S.

GENERAL SECRETARY.— M. ABDY COLLINS, M.D.

CHAIRMAN OF PARLIAMENTARY COMMITTEE.

H. WOLSELEY-LEWIS, M.D., F.R.C.S.

SECRETARY OF PARLIAMENTARY COMMITTEE.

R. H. COLE, M.D., M.R.C.P.

(both appointed by Parliamentary Committee, but with seats on Council).

SECRETARY OF EDUCATIONAL COMMITTEE.

J. G. PORTER PHILLIPS, M.D., M.R.C.P.

(appointed by Educational Committee, but with seat on Council).
registrar.— ALFRED MILLER, M.B,

MEMBERS OF COUNCIL.

REPRESENTATIVE.

E. H. BERESFORD
JOHN BRANDER
R. H. STEEN
T. SEYMOUR TUKE
T. E. K. STANSFIELDJ
II. T. S. AVELINE
W. F. NELIS
A. It. DOUGLAS
II. DEVINE
J. R. GILMOUR

js.E. Div.

S.W. Div.
l-N.&M. Div.

N. T. KERR
G. DOUGLAS McRAE

^ Scotland.

J. O'C. DONELAN
E. D. O'NEILL

|Ireland.

NOMINATED.

W. R. DAWSON
BERNARD HART
JAMES H. MACDONALD
G. E. PEACH ELL
G. M. ROBERTSON
R. O. ROWS
J. G. BOUTAR

[The above form the Council.]

auditors,

PERCY SMITH, M.D., F.R.C.P.

t R.

J DAVID BOWEK, M.D.

ENGLAND

SCOTLAND

EXAMINERS.

IE. D. MACNAMARA, M.D., F.R.C.P.

(J. SHAW BOLTON, M.D., D.So., F.R.C.P.
T. C. McKENZIE, M.D., F.R.C.P.

It. D. HOTCIIKIS, M.A., M.D.

J - NOLAN, L.R.C.P.

IRELAND | J RKDINUT 0N, F.R.C.S., L.R.C.P.I.
Examiners for the Nursing Certificate of the Association :

final.-JOHN KEAY, M.D., F.R.C.P.; R. R. LEEPER, F.R.C.S.;

F. It. P. TAYLOR, M.D.

Preliminary.— T. DRAPES, M.B.; H. J. McKENZIE, M.B.;

C II. G. GOSiWYCK, M.D., F.R.C P.

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PRINCETON UNIVERSITY

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PARLIAMENTARY COMMITTEE.

T. S. ADAIR.

H. T. S. AVELINE.

FLETCHER BEACH.

E. H. BERESFORI).

JAMES V. BLACHFORD.

DAVID BOWER.

LEWIS C. BRUCE.

R. B. CAMPBELL.

JAMES CHAMBERS.

R. H. COLE ( Secretary).

M. A. COLLINS (ex officio).

J. O’C. DON ELAN.

A. R. DOUGLAS.

TUOS. DRAPES.

J. R. GILMOUR.

W. GRAHAM.

P. T. HUGHES.

D. HUNTER.

THEO. B. HYSLOP.

ROBERT JONES.

N. T. KERR.

R. L. LANGDON-DOWN.

R. R. LEEPER.

J. R. LORD.

P. W. MACDONALD.

EDUCATIONAL

T. S. ADAIR.

3. R. ARMSTRONG-JONES.

H. T. S. AVELINE.

FLETCHER BEACH.

J. V. BLACHFORD.

1. J. S. BOLTON.

LEWIS C. BRUCE.

It. It. CAMPBELL.

JAMES CHAMBERS.

19. R. H. COLE.

M. A. COLLINS (ex officio).

2. MAURICE CRAIG.

H. DEVINE.

J. FRANCIS DIXON.

11. J. O'C. DONELAN.

A R. DOUGLAS.

THOS. DRAPES (ex officio).

J. R. GILMOUR.

G. H. G03TWYCK (ex officio).

12. W. GRAHAM.

18. B. HART.

R. D. HOTCIIKIS (ex officio).

17. P. T. HUGHES.

13. JOHN KEAY.

N. T. KERR.

R. R. LEEPER.

JOHN R. LORD (ex officio.)

G. I). McltAE.

H. j. n. Macdonald.

I*. W. MACDONALD.

4 . THOS. W. McDOWALL.

II. J. MACKENZIE (exofficio).

T. W. McDOWALL.

G. DOUGLAS McRAE.

W. F. MENZIES.

CI1AS. A. MERCIER.

JOHN MILLS.

W. F. NEL1S.

H. HAYES NEWINGTON.

M. J. NOLAN.

E. D. O’NEILL.

BEDFORD PIERCE.

HENRY RAYNER.

G. M.ROBERTSON.

SIR GEO. H. SAVAGE.

G. E. 8HUTTLEWORTH.

R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

T. E K. STANSFIELD.

R. H. STEEN.

ROTHSAY C. STEWART.

DAVID G. THOMSON.

T. SEYMOUR TUKE.

ERNEST WHITE.

H. WOLSELEY-LEWIS ( Chair -
mnn.)

COMMITTEE.

| T. C. MACKENZIE (ex officio).

1 16. W. TUACH MACKENZIE.

; 22. E. 1). MACNAMARA.

8. R. MACPHAIL.

W. F. MENZIES.

C. A. MERCIER.

JAMES MIDDLEMASS.

ALFRED MILLER (ex officio).

W. F. NELIS.

H. HAYES NEWINGTON.
MICHAEL J. NOLAN (ex officio).
E. D. O’NEIL.

DAVID ORR.

6. L. R. OSWALD.

J. G. PORTER PHILLIPS (Secy ).
BEDFORD PIERCE.

J. REDINGTON (ex officio.)

16. WILLIAM REID.

6. GEORGE M. ROBERTSON.

R. G. ROWS.

21. W. SCOWCROFT.

7. R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

T. E. K. STAN8FIELD.

8. ROBERT H. STEEN.

9. W. H. B. STODDART.

FREDERIC R. P. TAYLOR.

D. G. THOMSON.

10. T. SEYMOUR TUKE.

20. W. It. VINCENT.

LIBRARY COMMITTEE.

FLETCHER BEACH.
HELEN BOYLE.

M. A. COLLINS (ex officio).
HENRY DEVINE.
BERNARD HART.

THEO. B. HYSLOP.

E. MAPOTIIER (Secretary).
HENRY ItAYNER.

W. II. B. STODDART.

DAVID G. THOMSON (ex officio).

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Original from

PRINCETON UNIVERSITY

RESEARCH

T. STEWART ADAIR.

J. SIIAW BOLTON.

J. CHAMBERS.

M. A. COLLINS ( cx-ofino ).

H. DEVINE.

T. DRAPES.

E. GOODALL.

COMMITTEE.

J. R. LORD.

FORD ROBERTSON.

It. G. ROWS.

R. PERCY SMITH.

I). G. THOMSON (ex-officio).
W. J. TULLOCK.

Lectures at:—(l) University of Leeds ; (2) Guy’s Hospital; (3) St. Bartholomew’s
Hospital; (4) University of Durham; (5) University of Glasgow; (6) University of
Edinburgh and Medical College for Women, Edinburgh; (7) St. Thomas’s Hospital;
(8) King's College; (9) Westminster Hospital; (10) St. George's Hospital; (11)
University of Dublin and National University of Ireland ; (12) Queen's University of
Belfast; (13) Lecturer at School of Medicine, Roval Colleges and Medical College for
Women, Edinburgh; (14) St. Mungo's College, Glasgow; (15) Aberdeen University;
(16) St. Andrew's University and Dundee University ; (17) Birmingham University ;
(18) University College, London ; ^19) St. Mary’s Hospital, London; (20) University
of Sheffield ; (21) Victoria University, Manchester; (22) Charing Cross Hospital.

LIST OF CHAIRMEN.

1841. Dr. Uluke, Nottingham.

1842. Dr. de Vitre, Lancaster.

1843. Dr. Couolly, Hauwell.

1844. Dr. Thurnam, York Retreat.

1847. Dr. Wintlo, Warneford House, Oxford.

1851. Dr. Conolly, Hauwell.

1852. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS.

1854. A. J. Sutherland, M.D., St. Luku’a Hospital, London.

1855. J. Thurnam, M.D., Wilts County Asylum.

1856. J. Hitchmau, M.D., Derby County Asylum.

1857. Forbes Winslow, M.D., Sussex House, Hammersmith.

1858. John Conolly, M.D., County Asylum, Hauwell.

1859. Sir Charles Hastings, D.C.L.

1860. J. C. Buckuill, M.D., Devon County Asylum.

1861. Joseph Lulor, M.D., Richmond Asylum, Dublin.

1862. John Kirkman, M.D., Suffolk County Asylum.

1863. David Skac, M.D., Royal Edinburgh Asylum.

1864. Henry Munro, M.D., Brook House, Clapton.

1865. Win. Wood, M.D., Kensington House.

1806. W. A. F. Browne, M.D., Commissioner in Lunacy for Scotland.

1867. C. A. Lockhart Robertson, M.D., Haywards Heath Asylum.

1868. W. H. 0. Sankey, M.D., Sandy well Park, Cheltenham.

1869. T. Laycock, M.l)., Edinburgh.

1370. Robert Boyd, M.D., County Asylum, Wells.

1871. Henry Maudsley, M.D., The Lawn, Hauwell.

1872. Sir James Coxe, M.D., Commissioner in Lunacy for Scotland.

1873. Harrington Tuke, M.D., Manor House, Chiswick.

1874. T. L. Rogers, M.l)., County Asylum, Itainhill.

1875. J. F. Duncan, M.D., Dublin.

1876. W. II. Parser, M.D., Warwick County Asylum.

1877. G. Fielding Blandford, M.D., London.

1878. Sir J. Crichton-Browne, M.D., Lord Chancellor’s Visitor.

1879. J. A. Lush, M.D., Fisherton House, Salisbury.

1880. G. W. Mould,M.R.C.S., Royal Asylum, Cheadle.

1381. D. Hack Tuke, M.D., London.

1882. Sir W. T. Gairdner, M.D., Glasgow.

1883. W. Orange, M.D., State Criminal Lunntic Asylum, Broadmoor.

1884. Henry Rayner, M.D., County Asylum, Hauwell.

1835. J. A. Eames, M.D., District Asylum, Cork.

1886. Sir Geo. H. Savage, M.D., Bethlem Royal Hospital.

1387. Fred. Needham, M.D., Barnwood House, Gloucester.

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PRINCETON UNIVERSITY

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18S8. Sir T. S. Clouston, M.I)., Royal Edinburgh Asylum.

18s9. H. Hayes No wing ton, M.R.C.P., Ticehurst, Sussex.

1890. David Ycllowlces, M.D., Gartnavel Asylum, Glasgow.

1891. E. B. Whitcombe, M.R.C.S., City Asylum, Birmingham,

1892. Robert Raker, M.D., The Retreat, York.

1893. J. Murray Lindsay, M.I)., County Asylum, Derby.

1894. Conolly Norman, F.R.C.P.I., Richmond Asylum, Dublin.

1895. David Nicolson, C.R..M.D., State Criminal Lunatic Asylum, Broadmoor.

1896. William Julius Mickle, M.D., Grove Hall Asylum', Bow.

1897. Thomas W. McDowall, M.D., Morpeth, Northumberland.

1898. A. R. Urquhnrt, M.D., James Murray’s Royal Asylum, I’ertli.

1899. J. B. Spence, M.I)., Rurntwood Asylum, nr. Lichfield, Staffordshire.

1900. Fletcher Bench, M.B., 79, Wimpole Street, W.

1901. Oscar T. Woods, M.D., District Asylum, Cork, Ireland.

1902. J. Wiglesworth, M.D., F.R.C.P., Rninhill Asylum, near Liverpool.

1903. Ernest W.Wliite.M.B.,M.R.C.P..City of London Asylum,Dartford,Kent.

1904. R. Percy Smith, M.D., F.R.C.P., 36, Queen Anne Street, Cavendish

Square, Loudon, W.

1905. T. Outtcrson Wood, M.D., F.R.C.P., 40, Margaret Street, Cavendish

Square, London, W.

1900. Robert Jones, M.D., F.R.C.P., F.R.C.S., Claybury Asylum, Woodford
Bridge, Essex

1907. P. W. MacDonald, M.D., Counly Asylum, Dorchester.

1908. Chas.A.Mercier.M.D., F.R.C.P., F.R.C.S.,34, Wim pole Street, London, W.

1909. W. Bevan-Lewis, M Sc., L.R.C.P., Medical Director, West Riding

Asylum, Wakefield.

1910. John Macpherson, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Darnaway Street, Edinburgh.

1911. Win. R. Dawson, B A., M.D., F.R.C.P.I., D.P.H., Inspector of Lunatic

Asylums, Dublin Castle, Dublin.

1912. J. Greig Soutur, M.B., Medical Superintendent, Barnwood House,

Gloucester.

1913. James Chambers, M.A., M.D.R.U.I., The Priory, Roclmmpton, S.W.

1914. David G. Thomson, M.D., C.M.Edin., Medical Superintendent, County

Asylum, Thorpe, Norfolk.

HONORARY MEMBERS.

1896. Allbutt, Sir T. Clifford, K.C.B., M.D., I).Sc., LL.D., F.R.C.P., F.R.S.,
Regius Professor of Physic, Univ. Camb., St. Radegund’s, Cambridge.

1881. Deuedikt, Prof. M., Frauciskaucr Platz 5, Vienna.

1907. Bianchi, Prof. Leonardo, Manicoinio Proviuciale di Napoli. ( Cory. M> m.,
1896.)

1900. Blumer, G. Alder, M.D., L.R.C.P.Edin., Butler Hospital, Providence,
U.S.A. (Ord. Mem., 1890.)

1900. Bresler, Johannes, M.I)., Oberartzt, Liiben in Schlesicn, Germnny.
( Corr. Mem. 1896.)

1881. Brosius, Dr.,

1902. Brush, Edward N„ M.I)., Slieppnrd and Enoch Pratt Hospital, Towson,
Maryland, U.S.A.

1887. Chapin, John B., M.D., Cauandaigna, N.Y., U.S.A.

1909. Collins, Sir William J., D.L., M.D., M.S., B.Sc.I.ond., F.R.C.S.Eng.,
1, Albert Terrace, Regent’s Park, N.W.

1912. Cousidinc, Thomas Ivory, F.R.C.S.I., L.R.C.P.I., Inspector of Lunntic
Asylums, Ireland, Office of Lunatic Asylums, Dublin Castle, Dublin.

1902. Coapland, Sidney, M.D., F.R.C.P.Lond., Commissioner in Lunacy, 16,
Queen Anne Street, Cavendish Square, London, W.

1876. Crichton-Browne, Sir J., M.D.Edin., LL.D., D.Se., F.R.S., Lord
Chancellor’s Visitor, Royal Courts of Justice, Strand, W.C.,
and 45, Haus Place, S.W. (President, 1878.)

1911. Donkiu, Sir Horatio Bryan, M.A., M.D.Oxon., F.R.C.P.Lond. (Medical
Adviser to Prison Commissioners and Director of Convict Prisons),
28, Hyde Park Street, W.

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PRINCETON UNIVERSITY

Honorary and Corresponding Members.

1879. Echeverria, M. 0., M.D.

1896. Ferrier, Sir David, M.A., M.D., LL.D., F.R.C.P., F.E.S., 34, Cavendish

Square, London.

1872. Fraser, John, M.B., C.M., F.E.C.P.E., Formerly Commissioner in
Lunacy, 54, Great King Street, Edinburgh.

1898. Hine, George T., F.R.I.B.A., 35, Parliament Street, London, S.W.

1881. Hughes, C. IL, M.D., St. Louis, Missouri, United States.

1909. Kmepelio, Dr. Emil, Professor of Psychiatry, The University, Munich.
1887. Lentz, Dr., Asilc d’Alieues, Tounmi, Belgique.

1910. Macpherson, John, M.D., F.E.C.P.Edin., Commissioner in Lunacy, 8,

D.irnnwuy Street, Edinburgh. (Pbksidknt, 1910-11.) ( Ordinary

Member from 188(5.)

1898. Mngnau, V., M.D., Asile de Ste. Anne, Palis.

1912. Maudsley, Henry, LL.D.Edin., (Hou.), M.D.Loud., F.R.C.P.Lond.,
Heathbourne, Bnshey Heath, Herts. (Pbksident, 1871.) ( Formerly
Editor, Journal of Mental Science .)

1911. Moeli, Prof. Dr. Karl, Director, Uerzberge Asylum, Berlin.

1897. Morel, M. Jules, M.D., 50, Boulevard Leopold, Ghent, Belgium.

1889. Needham, Frederick, M.D.St. And., M.R.C.P.Edin., M.R.C.S.Eug.,
Commissioner in Lunacy, 19, Campdeu Hill Square, Kensington,
W. (Pbbsidknt, 1887.)

1909. Obcrsteiner, Dr. Heinrich, Professor of Neurology, The University, Vienna.
1881. Peetcrs, M., M.D., Gheel, Belgium.

1900. Ritti, Ant., 68, Boulevard Exelmans, Paris. (Corr. Mem., 1890.)

1887. Schiilc, Heinrich, M.D., lllcuuu, Baden, Germany.

1911. Semclaignc, Ren5, M.D.Paris, Secretaire des Seances de la Socield
Medico-Psychologique de Paris, 16, Avenue de Madrid, Ncuilly,
Seine, France. ( Corresponding Member from 1893.)

1881. Tamburiui, A., M.D., Rcggio-Emilia, Italy.

1901. Toulouse, Dr. Edouard, Directeur du Labovatoire de Psychologic experi¬

mental h l’Ecolc des Hautes Etudes Paris et Mcdecin eu chef de
l'Asile do Villejuif, Seine, France.

1910. Trevor, Arthur Hill, B.A.Oxon., of the Inner Temple, Barrister at Law,

Commissioner in Lunacy, 4, Albemarle Street, Loudon, W.

CORRESPONDING MEMBERS.

1904. Bierao, Gaetano, 48, Rua Formosa, Lisboune, Portugal.

1911. lloedeker, Prof. Dr. Justus Karl Edmund, Privat Dozent nnd Director,
Ficbhenhof Asylum, Schlactensee, Berlin.

1897. Buschnn, Dr. G., Stettin, Germuny.

1904. Caroleu, VVilfrid, Manicomia de Sta. Crur, St. Andreo de Palamar,
Barcelona, Spain.

1896. Cowan, F. M., M.D., 107, Perponchcr Straat, The Hague, Holland.

1902. Estensc, Benedetto Giovanni Selvatico, M.D., 116, Piazza Porta l’ia, Rome.

1911. Fnlkenberg, Dr. Wilhelm, Oberarzt, Irrenanstalt, Herzberge, Berlin.

1907. Ferrari, Giulio Cesnre, M.D., Director of the Manieomio Provinciale,
Imola, Bologna, Italy.

1911. Friedlander, Prof. Dr. Adolf Albrecht, Director of the Holie Murk Kliuik,
nr. Fraukfort.

1904. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.

1880. Komfeld, Dr. Hermann, Fr. Schlesien, Han’ptpostluyerstr., Breslau.

1889. Kowalowsky, Professor Paul, K hark off, Russia.

1895. Lindell, Emil Wilhelm, M.D., Sweden.

1901. Mauheimer-Gommfes, I)r., 32, Rue de 1’Arcn'le, Paris.

1909. Moreirn, l)r. Julien, M.D.Bahia, Professor and Director of the National
Manicomium of Rio de Janeiro ( Editor of the Brazilian Archices oj
Psychiatry , etc.).

1886. Parant, M. Victor, M.I)., Toulouse.

1909. Pilcz, Dr. Alexander (Professor of Psychiatry in the University of
Vienna), Superintendent Landossauatoriuin fur Norven und Geistes-
kranke Steinhof, Vienna.

1890. Regis, Dr. E, 61, Rue Huguerie, Bordeaux.

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PRINCETON UNIVERSITY

MEMBERS OF THE ASSOCIATION.

Digitized by

Alphabetical Lift of Members of the Association on Decetnber 31st, 1914, with
the year in which they joined. The Asterisk means Members who joined
between 1841 and 1856.

1900. Abbott, Henry Kingsmill, B.A., M.D.Dnb., D.P.H.Irel., Medical Superin¬
tendent, Hants County Asylum, Farcbam.

1891. Adnir, Thomas Stewart, M.D., C.M.Edin., F.R.M.S., Medical Superin¬
tendent, Stortbes Hull Asylum, Kirkhurton, near Huddersfield.
{Hon. Sec. N. and M. Division since 1908.)

1910. Adam, George Henry, M.R.C.S., L.R C.P. Loud., Manngcr and Medical
Superintendent, West Mailing Place, Kent.

1913. Adam*, John Barfield, L.R.C.P.AS.Edin., 119, Bcdlaml Rond, Bristol.
18G8. Adams, Josi.ill O., M.D.Durli., F.R.C.S.Eng., J.P., 117, Catenovc Rond,
Stamford Hill, N.

1880. Agar, S. Hollingsworth, jun., B.A.Cantab., M.R.C.S.Eng, L.S.A., Hurst
House, Heuley-iu-Arilen.

1869. Aldridge, Chas., M.D., C.M.Abcr., L.R.C.P.Lond., Bellevue House,
Plymptoh, Devon.

1905. Alexander, Edward Henry, M.B., C.M.r.din., M.R.C.S., L.R.C.P.Lond.,
M.P.C., Physician Superintendent, Ashbourne Hall Asylum, Dunedin,
New Zealand.

1899. Alexander, Hugh dc Maine, M.D., C.M.Edin., Medical Superintendent,
Aberdeen City District Asylum, Kingseat, Newmacliar, Aberdeen.
1899. Allmann, Dorah Elizabeth, M.B., B.Ch.R.U.I., Assistant Medical Officer,
District Asylum, Armagh.

1908. Anderson, James Richard Sumner, M.B., Ch.B.Glas., Senior Assistant
Medical Officer, Cumberland and Westmorland Asylum, Garlands,
Carlisle.

1898. Anderson, John Sewell, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, Hull City Asylum, Willerby,near Hull.

1912. Annandalc, James Scott, M.B., Ch.B.Edin., Second Assistant Physician,
Aberdeen Royal Asylum.

1912. Apthorp, Frederick William, M.RC.S.Eng., L.R.C.P.Edin., M.P.C.,

Senior Medical Officer, St. George’s Retreat, Ravensworth, Burgess
Hill.

1904. Archdale, Mcrvyu Alex., M.B., B.S.Durh., Medical Superintendent, East

Riding Asylum, Beverley, Yorks.

1905. Archdall, Mervyti Thomas, L.li.C.P.&S.Edin., L.S.A.Lond., Brynn-y-

Nenadd Hall, Llnnfairfechan, N. Wales.

1882. Armstrong-Joncs, Robert, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,
Medical Superintendent, London County Asylum, Claybury, Wood-
for<I, Essex. (Gen. Secretary from 1897 to 1906.) (President
1900-7.)

1910. Auden, G. A., M.A., M.I)., B.C., D.P.H.Cautab., M.R.C.P.Lond., F.S.A.,

Medical Superintendent, Educational Offices, Edmund Street,
Birmingham.

1891. Aveline, Henry T. S., M.D.Durli., M.R.C.S., L.R.C.P.Lond., M.P.C.,
Medical Superintendent, County Asylum, Cotford, near Taunton,
Somerset. {Hon. Sec. for S.W. Division, 1905-11.)

1911. Babington, Alice E. Mav, M.B., Ch.B.Edin., West Riding Asylum,

Wakefield.

1903. Bailey, William Henry, M.D.Lond., M.R.C.S.Eug., L.S.A.Lond., D.P.H.,
Featberstone Hall, Southall, Midd.

1891. Daily, Percy J., M.B., C.M.Edin., Medical Superintendent, London County
Asylum. Hanwcll, W.

1909. Bain, John, M.A., M.B., B.Ch.Glnsg., Assistant Medical Ofiicer, North¬
ampton County Asylum, Berrywood.

1913. Bainbridge, Charles Frederick, M.B., Ch.B.Edin., Assistant Medical

Officer, Devon County Asylum, Ex in in-ter.

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PRINCETON UNIVERSITY

Members of the Association. vii

1006. Baird, Harvey, M.D., Ch.B.Edin., Peritenu, Winchelsen, Snssex.

1878. Baker, H. Morton, M.B., C.M.Edin.,7, Belsize Square, London, N.W.
1888. Baker, John, M.D., C.M.Aberd., Medical Superintendent, State Asylum,

Broadmoor, Berks.

1904. Barham, Guy Poster, M.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Senior Assistant Medical Officer, Loudon Connty Asylum, Long-
Grove, Epsom.

1913. Barkley, Janies Morgan, M.B., Ch.B.Edin., Senior Medical Officer, Brace
Bridge Asylum, Lincolnshire.

1010. Bartlett, George Norton, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, City Asylum, Exeter.

1901. Barton, Samuel J., M.D., M.Ch.Duhl., Physician to the Norfolk and
Norwich Hospital, Surrey Street, Norwich.

1901. Baskin, J. Longhead, M.D.Brux., L.It.C.P.&S.Edin., L.R.F.P.S.Glas.,

Llangarran, Salisbury.

1902. Baugh, Leonard D. H., M.B., Ch.B.Edin., Tire Pleasnunce, York.

1893. Uaylcv, Joseph Herbert, M.B., C.M.Kdin., L.R.C.P.Lond., 11, The Mount,

Cavershnm, Reading.

1874. Beach, Fletcher, K.B., F.R.C.P.Lond.,/or/nerfy Medical Superintendent,
Darenth Asylum, Hartford; Strcsn, Downs Road, Coulsdon,
Surrey. (Secretary Parliamentary Committee, 1806-1906 General
Secretary, 1889-1896. President, 1900.)

1892. Beadles, Cecil F., M.R.C.S., L.R.C.P.Lond., The Clergy House, Englefield
Green, Surrey.

1902. Benle-Browne, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., Medical
Staff, South Nigeria, West Africa.

1913. Bedford, Percy William Page, M.B., Ch.B.Edin., County Asylum, Lan¬

caster.

1909. Bceley, Arthur, M.Sc.Leeds, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
D.P.H.Cumb. (Aeeietant Medical Officer, E. Sussex Educational
Committee), Windy bank, Kingston Road, Lewis.

1914. Bennett, James Woddersp on, M.R.C.S., L.R.C.P.Lond., Assistant

Medical Officer, County Mental Hospital, Stafford.

1912. Benson, Henry Porter D’Arcv, M.D., C.M.Kdin., M.R.C.P., F.R.C.S.

Edin., Medical Superintendent, Farnhain House, Finglns, Dublin.
1914. Benson, John Robinson, F.R.C.S.Eng., L.R.C.P.Lond., Resident Physi¬
cian and Proprietor, Fiddington House, Market Lavington, Wilts.

1899. Bcrosford, Edwyn H., M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

TootiDg Bee Asylum, Tooting, S.W.

1912. Berncastle, Herbert M., M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical,

Officer, Croydon Mental Hospital, Warlingham, Surrey.

1879. Bcvnn-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Lond., Elsinore,

Dyke Rond Avenue, Brighton. (President, 1909-10.)

1914. Biruie, Charlotte Murdoch, M.D., Ch.B.Edin., Assistant Medical Officer,
Camberwell Infirmary, London, S.E.

1894. Blachford, James Vincent, M.D., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,

M.P.C., City Asylum, Fishponds, Bristol.

1913. Black, Robert Sinclair, M.A.Edin., M.D., C.M.Aberd., D.P.IL, M.P.C.,

Senior Assistant Medical Officer, Valkenbnrg Asylum, Capo Town,
South Africn.

1908. Blackmore, Humphrey, P., M.D.St.Aud., M.R.C.S.Eng., L.S.A.Lond.,
Salisbury.

1898. Blair, David, M.A., M.D., C.M.Gla«g., County Asylum, Lancaster.

1897. Blaudford, Joseph John Guthrie, B.A., D.P.H.Camb., M.R.C.S.Eng.,
L.R.C.P.Lond., Medical Superintendent, Whalley Asylum, Lancs.
1908. Blandy, Gurth Swinncrton, M.D., Ch.B.Edin., Assistant Medical Officer
Middlesex County Asylum, Napsbury, Herts.

1904. Bodvel-Roberts, Hugh Frank, M.A.Cantab., M.R.C.S., L.R.C.P.Lond.,
L.S.A., Middlesex Connty Asylum, Napsbury, near St. Albans,
Herts.

1900. Bolton, Joseph Shaw, M.I)., B.S., D.Sc., F.R.C.P.Lond., Medical Super¬

intendent, West Riding Asylum, Wakefield.

Digitized by Google

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PRINCETON UNIVERSITY

Digitized by

▼iii Members of the Association.

1802. Bond, Charles Hubert, L).Sc., M.D., C.M.Edin., M.R.C.P.Loud., M.P.C.,
Commissioner in Lunacy, 66, Victoria Street, 5.W. {Hon. General
Secretary, 1906-12.)

1912. Borric, David Forbes, M.R.C.S.Eng., L.R.C.P.Lond., Bassorab, Turkish
Arabia, Persian Oulf.

1877. Bower, David, M.D., C.M.Aber.,Springfield House, Bedford. ( Chairman,
Parliamentary Committee, 1907-1910.)

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A. (address uncommuuicated).
1893. Bowes, William Henry, M.I)., B.S.Lond., F.lt.C.S.Eng., Medical Super¬
intendent, Plymouth Borough Asylum, Ivybridge, Devon.

1900. Bowles, Alfred, M.R.C.S., L.R.C.P.Lond., 10, South Cliff, Eastbourne.
1896. Boycott, Arthur N., M.D.Lond., M.R.C.S.Eng., L.R.C.P.Lond., Medicul
Superintendent, Herts Comity Asylum, Hill End, St. Albans, Herts.
(Hon. Sec. for S.-E. Dilution, 1900-05.)

1912. Boyd, William, M.B., Ch.B.Bclf. (address uncommunicated).

1898. Boyle, A. Helen A., M.D.Brux., L.lt.C.P.&S.Edin., 9, The Drive, Hove,
Brighton.

1883. Boys, A. H., L.R.C.P.Edin., M.R.C.S.Eng., L.S.A.Lond., The While
House, St. Albans.

1891. Braine-H.trtuell, George M. P., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, County and City Asylum, Powick, Worcester.

1911. Brander, John, M.B., C.B.Edin., Assistant Medical Officer, London

County Asylum, Bexley, Kent.

1895. Briscoe, John Frederick, M.R.C.S.,Eng., F.R.G.S., Resident Medical
Superintendent, Westbrooke House Asylum, Alton, Hants.

1905. Brown, Hairy Egcrton, M.D.,Ch.B.Glasg., M.P.C., West KoppiesAsylum,
Pretoria, S. Africa.

1908. Brown, Robert Cunyngham, M.D., B.S.Durh., General Board of Lunacy,
15, Rutland Square, Edinburgh.

1908. Brown, It. Dods, M.D., Ch.B., F.It.C.P.Edin., Dipl. Psych., D.P.II.,
Physician Superintendent, James Murray’s Royal Asylum, Perth.
1903. Brown, Ralph, M.B., B.S.Lond., M.ll.C.S., L.R.C.P.Lond., Bcthlcm
Royal Hospital, S.E.

1912. Brown, William, M.I)., C.M.Glas., District Medical Officer, Adviser in

Lunacy to Bristol Magistrates, Park View, Fishponds, Bristol.
1893. Bruce, Lewis C., M.D., F.R.C.P.Edin., M.P.C., Medical Superintendent,
District Asylum, Druid Park, Murthly, N.B. (Co-Editor of Journal
since 1911; Hon. Sec. for Scottish Division, 1901-1907.)

1913. Brunton, George Llewellyn, M.B., Ch.B.Edin., North Riding Asylum,

Clifton, York.

1912. Buchanan, Henry Meredith, M.B., Ch.B.Ediu., Mental Hospital, Seucliff,
Otago, N.Z.

1912. Buchanan, William Murdoch, M.B., Ch.B.Glas., Linden Bank, Lenzie,
Glasgow.

1892. Bullen, Frederick St. John, M.R.C.S.Eng., L.S.A.Lond., 3, Richmond

Park Road, Clifton, Bristol.

1908. Bullmore, Charles Cecil, J.P., L.lt.C.P.&S.Ediu., L.R.F.P.S.Glas., Medical
Superintendent, Flower House, Catford.

1912. Burke, Joseph D. G., M.B., Ch.B.R.U.I., Assistant Medical Officer,
District Asylum, Melton, Suffolk.

1911. Buss, Howard Dccimus, B.A., B.Sc.France, M.D.Brux.ACapc, M.R.C.S.,
L.R.C.P., L.M.S.S.A.Lond., Assistant Medical Officer, Fort
Beaufort Asylum, Cape Colony.

1910. Cahir, Joliu P., M.B., B.Ch.R.U.I., B.A.M.C. (address uueommuniented).
1891. Caldecott, Charles, M.B., B.S.Lond., M.ll.C.S., L.R.C.P.Lond., Medical
Superintendent, Enrlswood Asylum, Rcdhill, Surrey.

1889. Callcott, James T., M.D., B.S.Durh., M.R.C.S.Eng., Medical Superin¬
tendent. Borough Asylum, Newcast le-on-Tyne.

1913. Cameron, John Allan Mnnro, M.B., Ch.B.Glas., Pathologist, Scalebor
Park Asylum, Burlcy-iu-Wluirfednle, Yorks.

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Digitized by

Members of the Association. ix

1891. Campbell, Alfred Walter, M.D., C.M.Edin., Macquarie Chamber*, 183,
Mncquario Street, Sydney, New South Wales.

1909. Campbell, Donald Graham, M.B., C.M.Edin., “ Auchinillum,” 12, Reid-

haven Street, Elgin.

1914. Campbell, Finlay Stewart, M.D., C.M.Glus., District Medical Officer,
Glasgow Parish, 19, Westcrcraigs, Dennistoun, Glasgow.

1880. Campbell, Patrick E., M.B., C.M.Edin., Medical Superintendent, Metro¬
politan Asylum, Caterhain, Surrey.

1897. Curapbell, Robert Brown, M.D., C.M., F.R.C.P.E., Medical Superin¬
tendent, Stirling District Asylum, Larbert. ( Secretary for Scottish
Division from 1910.)

1911. Carlsson, Carl Petter, M.B., Ch.B.Edin. (address uiicommunicatcd).

1905. Carre, Henry, L.It.C.P.&S.Irel., Woodileo Asylum, Lenzic, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.R.F.P.S.Glasg., 43, Moray Place, Edin¬

burgh.

1874. Cassidy, I). M., M.D., C.M.MeGill Coll., Montreal, D.Sc. (Public Health)
Edin., F.lt.C.S.Edin., Medical Superintendent, County Asylum,
Lancaster.

1888. Chambers, James, M.A., M.D.R.U.T., M.P.C., The Priory, Roehampton.

( Co-Editor of Journal since 1905, Assistant Editor 1900-05.)
(PBK8IDENT, 1913-14.)

1911. Chambers, Walter Duncauon, M.A., M.D., Ch.B.Edin., M.P.C., Crichton
Royal Institution, Dumfries, N.B.

1865. Chapmnu, Thomas Algernon, M.D.Glas., L.R.C.S.Edin., F.Z.S., Betula,
Reigatc.

1907. Chislett, Charles G. A., M.B., Cb.B.Glasg., Assistant Medical Officer,
Woodilee Asylum, Lcnzie, Glasgow.

1880. Christie, J. W. Stirling, L.R.C.P.&S.Edin., Medical Superintendent,
County Asylum, Stafford.

1878. Clupham, Win. Crochley S., M.D., F.R.C.P.Ed., M.R.C.8., F.S.S., The
Five Gables, Mavfield, Sussex. {Hon. Sec. N. and M. Division,
1897-1901.)

1907. Clarke, Geoffrey, M.D.Lond., Senior Assistant Medical Officer, London
County Asylum, Runs!end, Sutton, Surrey.

1910. Clarke, James Kiliau P., M.B., B.Ch.R.U.I., D.P.H., High Street,

Oakham.

1907. Clarkson, Robert Durwnrd, B.Sc., M.D., C.M.Edin., F.R.C.P.Edin.

(Medical Officer, Scottish Nntioual Institute for the Education of
Imbecile Children), The Park, Larbert, Stirling.

1901. Clcland, William Lennox, M.B., C.M.Edin., Park Side, Adelaide, South
Australia.

18G2. Clouston, Sir Thomas S., M.D., LL.D.Edin., F.R.C.P., F.lt.S.E., 26, Heriot
Row, Edinburgh. ( Editor of Journal, 1873—1881.) (Pkesident,
1888.)

1892. Cole, Robert Henry, M.D.Lond , M.R.C.P.Loud., 25, Upper Berkeley

Street, W. ( Secretary of Parliamentary Committee since

1912.)

1900. Cole, Sydney John, M.A., M.D., B.Ch.Oxon., Medical Superintendent,
Wilts County Asylum, Devizes.

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Kent County Asylum, Maidstone.

1903. Collins, Michael Abdy, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Medical Superintendent, Ewell Colony, Epsom, Surrey. {Hon.
General Secretary since 1912.)

1910. Coulon, Thomas Peter, L.R C.P.&S.Irel., Resident Medical Superin¬
tendent, District Asylum, Monaghan.

1914. Couolly, Victor Lindley, M.B., B.Ch.Belfast, Assistant Medical Officer,
Colney Hatch Asylum, N.

1878. Cooke, Edward Marriott, M.D.Lond., M.R.C.S.Eug., Commissioner in
Lunacy, 69, Onslow Square, S.W.

1910. Coombes, Percivul Charles, M.R.C.S., L.R.C.P.Lond., Medical Superin¬
tendent, Surrey County Asylum, Nctherue.

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Members of the Association.

1905. Cooper, K. D., L.R.C.P.&S.Edin., L.R.F.P.S.Glas., e/o Leopold & Co.,
Apollo, Bunder, Bombay.

1903. Cormac, Harry Dove, M.B., B.S.Madras, Medical Superintendent,

Cheshire County Asylum, Macclesfield.

1891. Comer, Harry, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C., 37, Harley
Street, VV.

1905. Cotter, James, L.R.C.P.&S.E., L.R.F.P.S.Glas., Down District Asylum,
Downpatrick.

1897. Cotton, William, M.A., M.D.Edin., D.P.H.Cantab., M.P.C.,231,Gloucester
Road, Bishopston, Bristol.

1910. Coupland, William Henry, L.R.C.S.&I’.Edin., Senior Assistant Medical

Officer, 1, Sen View, South Road, Lancaster.

1913. Court, E. Percy, M.R.C.S., L.R.C.P.Lcnd., Sevcralls Asylum, Colchester.
1893. Cowcn, Thomas Philip, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, County Asylum, Rainhill, Lancashire.

1911. Cox, Donald Maxwell, M.R.C.S., L.R.C.P.Lond., The Hall, Headcorn,

Kent.

1884. Cox, L. F., M.R.C.S.Eng., Plas Caenneddyg, Llanbedr, R.S.O., Merioneth.

1893. Craig, Mnurice, M.A., M.D., B.C.Cantab., F.R.C.P.Lond., M.P.C., 87,

Harley Street, W. (Hon. Secretary of Educational Committee,
1905-8; Chairman of Educational Committee since 1912.)

1897. Cribb, Harry Gifford, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, Winterton Asylum, Ferryhill, Durham.

1911. Crichlow, Charles Adolphus, M.B, Ch.B.Glns. (address uncominuni-
ented).

1914. Crookshank, Francis Graham, M.D.Lond., M.R.C.P. (travelling), c/o 25,

Duke Street, Piccadilly, W.

1904. Cross, Harold Robert, L.S.A.Lond., F.R.G.S., Stortlics Hall Asylum,

Kirkburton, near Huddersfield.

1914. Cruickshnnk, J., M.l)., Ch.B.Glns., Pathologist, Crichton Royal Hospital,
Dumfries.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Cantab., M.R.C.S.,L.R.C.P.Lond,,
Senior Assistant Medical Officer, Loudon County Asylum, Han well, W.
1896. Davidson, Andrew, M.D., C.M.Abcr., M.P.C., Wyoming, Macquarie
Street, Sidney, N.S.W.

1911. Davie, James, M.B., Ch.B.Edin., 84, Braid Road, Edinburgh.

1914. Davies, Laura Katherine, M.B., Ch.B.Edin., Pathologist and Assistant
Medical Officer, Edinburgh City Asylum, Bangour, Dcchinout,
Linlithgowshire.

1891. Davis, Arthur N., L.R.C.P.&S.Edin., Medical Superintendent, County
Asylum, Exminster, Devon.

1894. Dawson, William K., B.A..M.D , B.Ch.Dubl.,F.R.C.P.I..D.P.H.,Insj ector

of Lunatics in Irelnnd, Claremout, Burlington Road, Duhliu. (Hon.
Sec. to Irish Division, 1902-11 ; President, 1911-12.)

1883. De Lisle, Samuel Ernest, L.R.C.P.&S.I., Krcaglnuore, Lower Bourne,
Furnhum, Surrey.

1901. De Steiger, Adble, M.D.Lond., County Asylum, Brentwood, Essex.

1905. Devine, Henry, M.D., B.S., M.U.C.P.Lond., M.R.C.S.Eng., M.P.C.,

Medical Superintendent, The Asylum, Milton, Portsmouth.

1904. Devon, James, L.R.C.P.&S.Edin., 1, North Park Terrace, Billhead,

Glasgow.

1903. Dickson, Thomas Graeme, L.R.C.P. & S.Ediu., Medical Superintendent,
Wye House, Buxton.

1909. Dillon, Kathleen, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Mullingar.

1905. Dixon, J. Francis, M.A., M.D., B.Ch.Dubl., M.P.C., Medical Super¬

intendent, Borough Asylum, Leicester.

1879. Dodds, William J., M.D., C.M., D.Sc.Edin., Glencoila, Bellahouston,
Glasgow.

1911. Donald, John Quin, L.R.C.P.&S.Edin., Medical Superintendent, Bally-
anghrim Sanatorium, Port Stewart, Co. Derry.

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Members of the Association.

1008. Donald, Robert, M.D., Ch.B.Glas., 3, Gilmour Street, Puisley.

1889. Donaldson, William Ireland, B.A., M.D., D.Cb.Dubl., Medical Super¬

intendent, County of Loudon Manor Asylum, Epsom, Surrey.

1802. Donelan, John O’Conor, L.R.C.P.AS.I., M.P.C., St. Dymphna’s, North
Circulur Rond, Dublin.

1902. Douglas, Archibald R., L.R.C.P.AS.Edin , L.R.F.P.S.Glas., M.P.C., Royal

Albert Asylum, Lancaster.

1890. Douglas, William, M.D.R.U.I., M.R.C.S.Eng., F.R.G.S., Brandfold,

Goudliurst, Kent.

1905. Dove, Augustus Charles, M.D., B.S.Durb.,M.R.C.S.Eng., “ Briglitside,”
Crouch End Hill, N.

1897. Dove, Emily Louisa, M.B.Loud., 11, Jcnner House, Hunter Street,
Brunswick Square, W.C.

1903. Dow, William Alex , M.D., B.S.Durb., M.R.C.8., L.R.C.P.Lond., D.P.H.,

II.M. Prison, Lewes.

1910. Downey, Michael Henry,M.B.,Ch.B.MeIb., L.R.C.P.AS.Edin., L.R.F.P.S.

Glasg., Assistant Medical Otlicer, Parkside Asylum, Adelaide, South
Australia.

1884. Drapes, Thomas, M.B.Dubl., L.R.C.S.I., Medical Superintendent, District
Asylum, Enniscorthy, Ireland. (Pbbsidbkt-blbct, 1910-11; Co-
Editor of Journal since 1912.)

1907. Drydcn.A. Mitchell, M.B., Ch.B.Edin., Bnrailly House, Lockerbie Road,
Dumfries.

1902. Dudgeon, Herbert Wm., M.D.Durh., M.R.C.S.Eng., L.R.C.P.Lond.,

Medical Officer to the Egyptian Asylum, Khanka Asylum, Egypt.

1899. Dudley, Francis, L.R.C.P.AS.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Corntvnll.

1903. Dunston, John Thomas, M.D., B.S.Lond., Medical Superintendent, West

Koppies Asylum, Pretoria, South Africa.

1913. Dyer, Sidney Reginald, M.D.Brux., L.R.C.P.Lond., M.R.C.S.Eng.,

L.S.A.Lond., D.P.H., Barrister-at-Law, Principal Medical Officer,
II.M. Prison, Brixton; 151, Brixton Hill, S.W.

1911. Dykes, Percy Armstrong, M.R.C.S., L.R.C.P.Lond., Senior Assistant

Medical Officer, Fulbourno Asylum, Cambridge.

1899. Eadcs, Albert I., L.R.C.P. A S.I., Medical Superintendent, North Riding

Asylum, Clifton, Yorks.

1874. Eager, Reginald, M.D.Loud., M.R.C.S.Eng., L.S.A.Lond. (address not
communicated).

1900. Eager, Richard, M.D., Ck.B.Abcr., M.P.C., Assistant Medical Officer,

Devon County Asylum, Exminster.

1873. Eager, Wilson, M.R.C.S., L.R.C.P., L.S.A.Lond., St. Aubyn’s, Wood-
bridge, Suffolk.

1881. Earle, Leslie M., M.D., C.M.Edin., 108, Gloucester Terrace, Hyde Park,
W.

1891. Earls, James Henry, M.D., M.Ch.R.U.I., D.P.H., L.S.A.Lond., M.P.C.,

Barrister-at-Law, Fcnstanton, Christchurch Road, Strcathnm Hill,
S.W.

1903. East, Guy Rowland, M.D., B.S.Durb., D.P.H., Northumberland County
Asylum, Morpeth.

1907. East, Wm. Norwood, M.D.Loud., M.R.C.S., L.R.C.P.Lond., M.P.C., H.M.

Prison, Manchester; also 171, Cheetlmm Hill Road, Manchester.
1895. Eastcrbrook, CharlesC.,M.A.,M.D., F.lt.C.P.Ed., M.P.C., J.P., Physician
Superintendent, Criehton Rovnl Institution, Dumfries.

1914. Eder, M.D., B.Sc.Loud., M.R.C.S.Eng., L.R.C.P.Lond., Medical Officer,

Deptford School Clinic, 7, Welbeck Street, W.

1895. Edgerley, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superinten¬
dent, West Riding Asylum, Menston, nr. Leeds.

1897. Edwards, Francis Henry, M.D.Brux., M.R.C.P.Lond., M.R.C.S.Eng.,
Medical Superintendent, Camberwell House, S.E.

1901. Elgce, Samuel Charles, L.R.C.P.AS.I., Senior Assistant Medical Officer,

London County Asylum, Colncy Hatch, N.

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xii Members of the Association.

1889. Elkins, Frank Ashby, M.D., C.M.Edin., M.P.C., Medical Superintendent,

Metropolitan Asylum, Leavesden, Herts.

1898. Ellerton, Henry B., M.R.C.S., L.R.C.P. Loud., Inspector of the Insane,

Hospital for the Insane, Goodua, Brisbane, Queensland, Australia.
1912. Ellerton, John Frederick Heise, M.D.Brux., M.R.C.S.Eng., L.R.C.P.
Edin , Rotherwood, Leamington Spa.

1890. Ellis, William Gilmore, M.D.Brux., M.R.C.S.Eng., L.S.A.Lond., J.P.,

Principal Civil Medical Officer, Singapore, Straits Settlements.

1908. Ellisou, Arthur, M.R.C.S., L.R.C.P.Eng., Deputy Medical Officer, 11.M.

Prison, Leeds, 120, Domestic Street, Holbcck, Leeds.

1899. Ellison, F. C., B.A., M.D., B.Ch.Dub., Resident Medical Superintendent,

District Asylum, Castlebar.

1911. Etnslic, Isabella Galloway, M.D., Ch.B.Edin., West House, Royal Asylum,
Moruingside, Edinburgh.

1911. English, Ada, M.B., B.Ch.ILU.I., Assistant Medical Officer, District
Asylum, Balliuasloe.

1901. Erskiuc, Win. J. A., M.D., C.M.Edin., Senior Assistant Medical Officer,
,City Asylum, Nottingham.

1895. Euricb, Frederick Wilhelm, M.D., C.M.Edin., 8, Mornington Villas,
Maningkam Lane, Bradford.

1894. Eustace, Henry Marcus, B.A., M.D., B.Cli.Dubl., M.P.C., Medical
Superintendent, Hampstead and High field Private Asylum,
Glasneriu, Dublin.

1909. Eustace, William Ncilson, L.R.C.S.AP.Ircl., Lisronngh, Glasuevin, co.

Dublin.

1909. Evans, George, M.B.Lond., Senior Assistant Medical Officer, Sevcralls
Asylum, Colchester.

1891. Ewan, John Alfred, M.A. St. And., M.D., C.M.Edin., M.P.C., Greyness,

Sleaford, Lines.

1884. Ewart, C. T., M.D., C.M.Aberd., Senior Assistant Medical Officer,
Claybury Asylum, Woodford Bridge, Essex.

1906. Ewens, George Francis William, Major I.M.S. Bengal, c/o Messrs.

Griudlay & Co., 54, Parliament Street, S.W.

1914. Ewing, Cecil Wilmot, L.R.C.P.I. & L.R.C.S.I., Second Assistant Medical
Officer, Chatham Asylum, near Canterbury.

1907. Exley, John, L.R.C.P.I., M.R.C.S.Eng., Medical Officer, H.M. Prison;

Grove House, New Wortley, Leeds.

1894. Farquharson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬
tendent, Counties Asylum, Garlands, Carlisle.

1907. Farries, John Stothnrt, * L.R.C.P.AS.Edin., L.R.F.P.S.Glas., Medical

Superintendent, Minda Home, Adelaide, South Australia.

1908. baulks^ Edgar, M.R.C.S., L.R.C.P.Lond., Senior Assistant Medical

Officer, London County Asylum, Bexley.

1903. Fennell, Charles Henry, M.A.. M.D.Oxon, M.lLC.P.Loud., The Manor
House, West Hoathly, East Grinstead.

1908. benton, Henry Felin, M.B., Ch.B.Edin., Assistant Medical Officer,
County and City Asylum, Powick, Worcester.

1907. berguson, J. J. Harrowcr, M.B., Ch.B.Edin., Scuior Assistant Medical
Officer, Fife and Kinross Asylum, Cupnr, Fife.

1897. Fielding, James, M.D., Viet. Univ., Canada, M.R.C.S.Eng. "L.R.C.P.

,. Edin., 18, The Crescent, Norwich.

1906. bidding, Saville James, M.B., B.S.Durh., Medical Superintendent,
Bethel Hospital, Norwich.

1873. Finch, John E. M., M.A., M.D.Cantab., M.R.C.S.Eng., L.S.A.Lond.,
Holmdnlc, Stoueygatc, Leicester.

1889. Finch, Richard T., B.A., M.B.Cantab., M.R.C.S.Eng., L.S.A.Lond.,
Medical Suncrintendent, Fisherton House, Salisbury.

1889. b inlay, David, M.D., C.M.Glasg., Medical Superintendent, County
Asylum, Bridgend, Glamorgan.

1906. Firth, Arthur Harcus, M.A., M.D., B.Ch.Edin., Deputy Medical Super¬
intendent, B trnsley Hall, Bromsgrove, Worcestershire.

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Xlll

Members of the Association.

1903. Fitzgerald, Alexis, L.R.C.P. & S.I., District Asylum, Waterford.

1894. Fitzgerald, Charles E., M.D., M.C'h.Dubl., F.R.C.S.I., Surgeon-Oculist

to the King in Ireland, President of the Koyal College of Physicians
of Ireland, 27, Upper Merriou Street, Dublin.

1888. Fitz-Gcrald, Gerald C., B.A., M.D., 11.C.Cantab., M.P.C., Medical Superin¬
tendent, Kent County Asylum, Chartlmm, nr. Canterbury.

190S. Fitzgerald, James Francis, L.R.C.P.AS.Ircl., Assistant Medical Officer,
District Asylum, Clonmel, Ireland.

1904. Fleming, Wilfrid Louis Rctni, M.R.C.S., L.R.C.P.Lond., Suffolk House,

Pirbriglit, Surrey.

1891. Floury, Eleonora Lilian, M.D., H.Cb.R.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

1908. Flynn, Thos. Aloyaius, L.R.C.P.AS.T., County Asylum, Thorpe, Norwich.
1902. Forde, Michael J., M.D., B.Ch.H.U.I., Assistant Medical Officer, Port-

rune Asylum, Ireland.

1911. Forrester, Archibald Thomas William, M.D., B.S., M.R.C.S., L.R.C.P.

Lond., Senior Assistant Medical Officer, Leicester and Rutland
Counties Asylum, Narborough.

1913. Forward, Ernest Lionel, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, The Coppice, Nottingham.

1913. Fothergil), Claude Francis, B.A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P.
Lond., Hensol, Chorley Wood, Herts.

1909. Foulerton, Alexander Grant Russell, F.R.C.S.Eng., L.R.C.P.Loud.,

D.P.H.Cnntab. (County Medical Officer of Health for E. Sussex),
Middlesex Hospital, W., Wcaldsidc, Lewes.

1861. Fox, Charles H., M.D.St. And., F.R.C.P.E., M.R.C.S.Eng., 36, Heriot
Row, Edinburgh.

1912. Fox, Charles J., M.R.C.S.Eng., L.R.C.P.Lond., Blidworth, Notts.

1881. Fraser, Donald, M.D., C.M.Glasg., F.R.F.P.S., 13, Royal Terrace,
West Glasgow.

1901. French, Louis Alexander, M.R.C.S., L.R.C.P.Lond., H.M. Prison, Port¬

land, Dorset.

1902. Fuller, Lawrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬

intendent, Three Counties’ Asylum, Hitchin, Herts.

1914. Gage, John Munro, L.R.C.P.&S.I., The Retreat, York.

1906. Gnne, Edward Palmer Steward, M.D.Durh., M.R.C.S., L.R.C.P.Lond.,
Cotherstonc, Yorks.

1912. Garry, John William, M.B., B.Cli., N.U.I., Assistant Medical Officer,
Ennis District Asylum, Ireland.

1912. Gavin, Lawrence, M.B., Ch.B.Ediu,, L.It.C.P.&S.Edin., L.R.F.P.S.
Glasg., Superintendent, Mullingar District Asylum, Ireland.

1885. Gay ton, Francis C., M.D., C.M.Aberd., M.R.C.S.Eng., Much Hadlmm,
Herts.

1908. Genie, William James, L.R.C.P.Edin., L.lt.F.P.S.Glasg. (address un¬
communicated).

1896. Geddes, John W., M.B., C.M.Ediu., Medical Superintendent, Couuty
Borough Asylum, Berwick Lodge, Middlesbrough, Yorks.

1892. Gcmmel, James Francis, M.B.Glasg., Medical Superintendent, County
Asylum, Whittingham, Preston.

1914. Gettings, Harold Salter, L.R.C.P. & S.Edin., L.F.P.S.G., D.P.H.Birm.,
Pathologist, West Riding Asylum, Wakefield.

1899. GilfiUnn, Samuel James, M.A., M.B., C.M.Ediu., Medical Superin¬
tendent, London Couuty Asylum, Culuey Hatch.

1910. Gilfillan, William, M.B., Ch.B.Glasg., Alma Lane, Falkirk.

1912. Gill, Eustace Stanley Hayes, M.B., Ch.B.Liverp., Shaftesbury House,
Formby, Liverpool.

1889. Gill, Stanley A., B.A.Dubl., M.D.Durh., M.R.C.P.Lond., M.R.C.S.Eng.,
Shaftesbury House, Formby, Liverpool.

1904. Gillespie, Daniel, M.D. B.Ch.R.U.L, Dipl. Psych., Wadsley Asylum,
near Sheffield.

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xiv Members of the Association.

1897. Gilinonr, John Rutherford, M.R., C.M., F.R.C.P.Edin., M.P.C., Medical

Superintendent, Went Riding Asylum, Scnlebor Park, Burley-iu-
Wharfedale, Yorks.

190(5. Gil rour, Richard Wither*, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Loud.,
Homewood House, West Meon, Hants.

1878. Glcndiuuing, James, M.D.Glusg., L.R.C.S.Edin., Hill Court, Lunsdown
R >ad, Abergavenny.

1898. Goldie-Scot, Thomas G„ M.B., C.M.Ediu., M.R.C.S., L.R.C.P.Loud.,

Pilmuir, Peucaitland, N.B.

1897. Good, Thomas Snxty, M.R.C.S.Eng., L.R.C.P.Loud., Medical Superin¬
tendent, County Asylum, Littlemore, Oxford.

1889. Goodull, Edwin, M.D., B.S., F.R.C.P.Lond., M.P.C., Medical Superin-
tendeut, City Asylum, Cardiff.

1899. Gordon, James Leslie, M.D., C.M.Aberd., Medical Superintendent,

Fountain Tempor.iry Asylum, Tooting Grove, Tooting Graveney,
S.W.

1905. Gordon-Muun, John Gordon, M.D.Edin., F.R.S.E., Hcigham Hall,
Norwich.

1901. Gostwyck, C. H. G., M.B., Cli.B., M.R.C.P.Edin., M.P.C., Dipl. Psych.,
Stirling District Asylum, Larbert.

1912. Grnhain, Gilbert Mulise, M.B., Ch.B.Edin., R.N College, Greeuwicli.
1914. Graham, Norman Bell, B.A., R.U.I., M.B., B.Ch.Belfast, Assistant
Medical Officer, District Asylum, Belfast.

1894. Graham, Samuel, L.R.C.P.Loud., Resilient Medical Superintendent,
District Asylum, Antrim.

1387- Graham, William, M.D.R.U.I., L.R.C.S.Edin., Medical Superintendent,
District Lunatic Asylum, Belfast.

1908. Graham, William S., M.B., B.Ch.R.U.I., Assistant Medical Officer,

Somerset and Bath Asylum, near Taunton.

1909. Greene, Thomas Adrian, L.R.C.S.AP.Irel., J.P., Medical Superintendent,

District Asylum, Carlow.

1886. Greenlees, T. Duncan, M.D., C.M.Edin., F.R.S.E., Rostrevor, Kirtleton
Avenue, Weymouth.

1912. Greeson, Clarence Edward, M.D., Ch.B.Aberd., Surgeon, R.N.

1904. Griffin, Ernest Harrison, B.A.Cautab., L.S.A.Lond. (address uncora-
mnnicated).

1901. Grills, Galbraith Hamilton, M.D., B.Ch.R.U.I., Dipl. Psych., Medical
Superintendent, “ Elmwood," Liverpool Road, Chester.

1900. Grove, Ernest George, M.R.C.S., L.R.C.P.Loud., Buotham Park,
York.

1894. Gwynn, Charles Henry, M.D., C.M.Edin., M.R.C.S.Eng., co-Licensee,
St. Mary’s House, Whitchurch, Salop.

1894. Halsted, Harold Cecil, M.D.Durh., M.R.C.S., L.R C.P.Lond., Manor
Road, Selsey, Sussex.

1903. Ilanbury, Langton Fuller, M.R.C.S.Eng., L.R.C.P.Loud., Medical Super¬

intendent, West Ham Borough Asylum, Ilford, Essex.

1901. Harding, William, M.D.Edin., M.R.C.P.Lond., Medical Superintendent,
Northampton County Asylum, Berry Wood, Northampton.

1899. Harmcr, W. A., L.S.A., Resident Superintendent and Licensee, Redlands
Private Asylum, Tonbridge, Kent.

1904. Harper-Smith, George Ilastie, B.A.Cantab., M.R.C.S., L.R.C.P.Loud.,

Senior Assistant Medical Officer, Brighton County Borough Asylum,
Haywards Heath.

1898. Harris-Liston,L.,M.D.Brux.,M.R.C.S., L.R.C.P.Lond., L.S. A., Middleton
Hall, Middleton St. George, Co. Durham.

1905. Hart, Bernard, M.D.Lond., M.R.C.S.Eng., 29 b, Wimpole Street, and

Northumberland House, Finsbury Park, N.

1836. Harvey, Bugenal Crosbie, L.R.C.P.AS.Edin., L.A.H.Dubl., Resident
Medical Superintendent, District Asylum, Clonmel.

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Members of the Association. xv

1892. Ilaslett, William Jolm H., M.R.C.S., L.R.C.P.Lond., M.P.C., Resident
Medical Superintendent, Halliford House, Upper Halliford, Shop-
perton.

1891. Havelock, John O., M.I).,C.M.Edin., Little Stolidani, Lii-s, Hants.

1890. Hay, J. F. S„ M.Ib, C.M.Aberd., Inspector-General of Asylums for New
Zealand, Government Buildings, Wellington, New Zealand.

1900. Haynes, Horace E., M.lt.C.S.Kug., L.S.A., J.P., Littleton Hall, Brent*
wood.

1895. Henrder, Frederic P., M.D., C.M.Kdin., Medical Superintendent, York¬
shire Inebriute Reformatory, Cattnl, Whixley, near York.

1911. Heffernnn, Capt. P., B.A., M.B., B.Cli.C.U.I., Locock’s Gardens,

Kilpauli, Madras.

1905. Henderson, George, M.A., M.B., Clt.B.Edin., 25, Commercial Road,
IVckham, S.E.

190C. Herbert, Thomas, M.R.C.S., L.R.C.P.Lond., York City Asylum, Fulford,
York.

1877. Hetherington, Charles E., B.A., M.B., M.Ch.Dubl., Medical Superin¬
tendent, District Asylum, Londonderry, Irelaud.

1877. Hewson, U. W., L.R.C.P.&S.Edin., Medical Superintendent, Coton Hill,
Stafford.

1914. Hewson, R. W. Dale, L.R.C.P.&S.Edin., L.R.F.P.&S.GIas., Coton Hill
Hospital, Stafford.

1902. Higginson, John Wigmore, M.R.C.S., L.R.C.P.Lond., Resident Medical

Officer, Hayes Park Asylum, Hayes Park, Middlesex.

1912. Higson, William Davis, M.B., Ch.B.Liverp., D.P.H., Deputy Medical

Officer, H.M. Prison, Brixton; 7, Clovelly Gardens, Upper Tulse
Hill, S.W.

1882. Hill, H. Gardiner, M.R.C.S.Eng., L.8.A., Pentillie, Leopold Road,
Wimbledon Park, S.W.

1914. Hills, Harold William, B.S., M.B., B.Sc.Lond., M.R.C.S., L.R.C.P.Lond.,
B.A.M.C.

1907. Hine, T. Guy Macaulay, M.A., M.D., B.C.Cnntab., 37, Hertford Street,

Mayfair, W.

1909. Hodgson, Harold West, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Severalls Asylum, Colchester.

1908. Hogg, Archibald, M.B., Ch.B.Glns., 54, High Street, Paisley, N.B.

1900. Holl&uder, Bernard, M.D.Froib., M.R.C.S., L.R.C.P.Lond, 67, Wimpole

Street, W.

1912. Holyoak, Walter L., M.D., B.S.Lond., 77, Welbeck Street, W.

1903. Hopkins, Charles Leighton, B.A., M.B., B.C.Cantab., Medical Superin¬

tendent, York City As) lum, Fulford, York.

1918. Hopwood, Joseph Stanley, M.B., B.8., M.R.C.S., M.R.C.P.Lnnd.,
Sunn) bank House, Cornholine, Todmorden, Lancs.

1894. Hotchkis, Robert D., M.A.Glasg., M.D., B.S.Dnrh., M.R.C.S., L.R.C.P.

Loud., M.P.C., Renfrew Asylum, Dykcbar, N.B.

1907. Howard, S. Carlisle. M.D., Ch.B.Aberd., Senior Assistant Medical Officer,
Countv Asylum, Chester.

1912. Hughes, Frank Percival, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,The

Grove, Pinner, Middlesex.

1900. Hughos, Percy T., M.B., C.M.Kdin., D.P.H., Medical Superintendent,
Worcestershire County Asylum, Barnseley Hall, Bromsgrove.

1913. Hughes, Robert, M.B.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C. ( School

Medical Officer, County Borouyh of Stoke-on-Trent), Heron House,
Fenton, Stoke-on-Trent.

1904. Hughes, William Stanley, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Shropshire County Asylum, Bicton Heath,
Shrewsbury.

1897. Hunter, David, M.A., M.H., B.C.Cantab., L.S.A., Medical Superintendent,
The Coppice, Nottingham. ( Secretary for S.E. Division, 1910-
1913.)

1909. Hunter, Douglas William, M.B., Ch.B.Glnsg., Assistant Medical Officer,

10, Ilalliield Road, Bradford.

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xvi Members of the Association.

1912. Hnnter, George Yeates Cobb, Colonel, F.M.S., M.R.C.S., L.R.C.P.Lond.,
M.P.C., c/o Messrs. Grindlay & Co., 54, Parliament Street, S.W.
1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., Three Counties
Asylum, near Hitcliin.

1882. Hyslop, James, D.S.O., M.B., C.M.Edin., Medical Superintendent, Natal
Government Asylum, Pietermaritzburg.

1888. Hyslop, Tlieo. B., M.D., C.M.Edin., M.R.C.P.E., L.R.C.S.E., F.R.S.E.,
5, Portland Place, London, IV.

1908. Inglis, J. P. Park., M.B., Ch.B.Edin., Assistant Medical Officer,
Fountain Temporary Asylum, Tooting Grove, Tooting Graveney,
S.W.

1906. Irwin, Peter Joseph, L.R.C.P.AS.I., Assistant Medical Officer, District
Asylum, Limerick.

1911. Jackson, David James, B.A., M.D., B.Ch.R.U.I., Assistant Medical

Officer, Mental Hospital, Cardiff.

1914. James, George William Blomfield, M.B., B.S.Lond., Resident Medical
Officer, Moorcroft, Hillingdon, Uxbridge.

1908. Jeffrey, Geo. Rutherford, M.D., Ch.B.Glas., F.R.C.P.E., M.P.C.,
Medical Superintendent, Bootliam Park, York.

1907. Jex-Blake, Bertha, M.B., Ch.B.Edin., 13, Ennismore Gardens, S.W.
1910. Johnson, Cecil, M.B., Ch.B.Vict., “ Cricklewood,” East Sheen, S.W.
1893. Johnston, Gerald Herbert, L.R.C.S.&P.Edin., L.R.F.P.S.Glas., Brooke
House, Upper Clapton, N.

1905. Johnston, Thomas Leonard, L.R.C.P.AS.Edin., L.R.F.P.S.Glas., Medical
Superintendent, Bracebridge Asylum, Lincoln.

1912. Johnstone, Emma May, L.R.C.P. & S.Edin., L.R.F.P.S.Glas., M.P.C.,

Dipl. Psych., Holloway Sanatorium, Virginia Water, Surrey.

1878. Johnstone, J. Carlyle, M.D., C.M.Glas., Medical Superintendent, Rox¬
burgh District Asylum, Melrose.

1880. Jones, D. Johnston, M.D., C.M.Edin. (travelling).

1879. Kay, Walter S., M.D., C.M.Edin., M.R.C.S.Eng., 1, Rutland Park,
Sheffield.

1886. Keay, John, M.D., C.M.Glasg., F.R.C.P.Edin., Medical Superintendent,
Bangour Village, Uplinll, Linlithgowshire.

1909. Keith, William Brooks, M.B., Ch.B.Aberd., M.P.C., Army Medical Corps.
1909. Kellas, Arthur. M.B., Cli.B., D.P.H.Aberd., Senior Assistant Physician,
Royal Asylum, Aberdeen.

190S. Kelly, Richard, M.D., B.Ch.Dub., Assistant Medical Officer, Storthcs
Hall Asylum, Kirkburton, near Huddersfield.

1907. Keene, George Henry, M.D., The Asylum, Goodmayes, Ilford, Essex.

1898. Kemp, Norah, M.B., C.M.Glas., Hill Rise, The Mount, York.

1899. Kennedy, Hugh T. J., L.R.C.P.&S.I., Assistant Medical Officer, District

Asylum, Enniscorthy, Wexford.

1897. Kerr, Hugh, M.A., M.D.Glasg., Medical Superintendent, Bucks County
Asylum, Stone, Aylesbury, Bucks.

1902. Kerr, Neil Thomson, M.B., C.M.Ed., Medical Superintendent, Lannrk

District Asylum, Hartwood, Shotts, N.B.

1893. Kershaw, Herbert Warren, M.R.C.S.Eng., L.R.C.P.Lond., Dinsdale Park,
near Darlington.

1897. Kidd, Harold Andrew, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, West Sussex Asylum, Chichester.

1903. King, Frank Raymond, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Peckham House, Peckham, S.E.

1897. Kingdon, Wilfred, M.B., B.S.Durh., 160, Goldhawk Road, W.

1902. King-Turner, A. C., M.B.,C.M.Edin., The Retreat, Fairford, Gloucester¬
shire.

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1899. Kirwan, James St. L., B. A., M.B., B.Cli.R.U.I., Medical Superintendent,
District Asylum, Ualliniudoe, Ireland.

1903. Rough, Edward Fitzadam, B.A., M.B., B.Cli.Dubl., Senior Assistant
Medical Officer, County Asylum, Gloucester.

1898. Labey, Julius, M.R.C.S., L.R.C.P., L.S.A.Lond., Medical Superin¬
tendent, Public Asylum, Jersey.

1902. Langdon-Down, Percival L., M.A., M.B., B.C.Cautab., Normausfield,
Hampton Wick, Middlesex.

1896. Langdon-Down, Reginald L., M.A., M.B., B.C.Cnntnb., M.R.C.P.Lond.,
Normansfield, Hampton Wick.

1914. Ladell, R. G. Macdonald, M.B., Ch.B.Vict., Shafton House, Holbeck,
Leeds.

1909. Laurie, James, M.B., Cli.M.Glasg. (Medical Officer, Smithslon Asylum),
Red House, Ardgowan Street, Greenock.

1902. Laval, Evariste, M.B.,C.M.Kdin., The Guildhall, Westminster, S.W.

1898. Lavers, Norman, M.D.Brux., M.R.C.S., L.ll.C.P.Lond., Medical Super¬

intendent, Bailbrook House, Bath.

1899. Law, Charles D., L.R.C.P.AS.Edin., L.R.F.P.S., 117, Wilderspool Road,

Warrington.

1892. Lawless, George Robert, F.R.C.S.I., L.R.C.P.I., Medical Superintendent,
District Asylum, Armagh.

1870. Lawrence, Alexander, M.A., M.D., C.M.Aberd., 2G, Hough Green,
Chester.

1883. Lnyton, Henry A., M.R.C.S.Eng., L.R.C.P.Edin., Podington, near Wel¬
lingborough.

1909. Leech, John Frederick Wolseley, M.D., B.Ch.Dubl., County Asylum,
Devizes, Wilts.

1899. Leeper, Richard It., F.R.C.S.I., M.P.C., Medical Superintendent, St.

Patrick’s Hospital, Dublin. {Hon. Sec. to the Irish Division from
1911.)

1883. Legge, Richard J., M.D., R.U.I., L.ll.C.S.Edin., Medical Superintendent,
County Asylum, Mickleover, Derby.

1906. Leggett, William, B.A., M.P B.Ch.Dubl., Assistant Medical Officer,
Royal Asylum, Sunnyside, .Montrose.

1894. Lentaigne, Sir John, B.A., F.R.C.S.I., L.R.C.P.I., Medical Visitor of
Lunatics to the Court of Chancery, 42, Merrion Square, Dublin.
1863. Ley, H. Rooke, M.R.C.S.Eng., Beaulieu, Westhy Road, Boscombc, Hunts.
1914. Lindsay, David George, L.R.C.P., L.R.C.S.Edin., Senior Assistant Medi¬
cal Officer, Dundee District Asylum, West Green, Dundee.

1908. Littlejohn, Edward S ilteine, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, London County Asylum, Cane Hill, Surrey.

1903. Logan,’ Thomas Stratford, L.R.C.P.&S.Edin., L.R.F.P.S.Gias., D.P.H.,

Stone Asylum, Aylesbury, Bucks.

1898. Lord, John R., M.B., C.M.Edin., Medicnl Superintendent, London County

Asylum, Horton, Epsom. {Co-Editor of Journal since 1911; Assis¬
tant Editor of Journal, 1900-11.)

1906. Lowry, James Arthur, M.D., M.B., B.Ch., R.U.I., Medical Superinten¬
dent, Surrey County Asylum, Brookwood.

1901. Lyall, C. H. Gibson, L.R.C.P.&S.Edin., Leicester Borough Asylum,
Leicester.

1872. Lyle, Thomas, M.D., C.M.Glasg., 34, Jesmond Road, Newcsstle-on-Tyno

1906. Macarthur, John, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
Colney Hatch Asylum, London, N.

1899. Macartney, William H.C., L.R.C.P.&S.I., Riverhend House, Sevenoaks.
1880. MacBryan, Henry C., L.R.C.P. & S. Edin., Kingsdovrn House, Box, Wilts.

1900. McClintock, John, L.R.C.P.&S.Edin., Resident Medical Superintendent,

Grove House, Church Stretton, Salop.

1900. McConaghey, John C., M.D., Ch.B.Edin., Medical Superintendent,
Parkside Asylum, Macclesfield, Cheshire.

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Xviii Members of the Association.

1901. MacDonald, James H., M.B., Ch.B., F.R.F.P.S.Glnsg., Govan District

Asylum, Hawkhead, Paisley, N.B.

1884. MacDonald, P. W., M.D., Ch.M.Aberd., Medical Superintendent, Dorset
County Asylum, Herrison, Dorchester. ( First Hon. Sec. S.1T.
Division 1894 to 1905.) (President, 1907-8.)

1911. MacDonald, Ranald, M.D., Ch.B.Ediu., Assistant Medical Officer, London
County Asylum, Bexley, Kent.

1905. MacDonald, William Fraser, M.B., Ch.B.Edin., M.P.C., 96, Polworth
Terrace, Edinburgh.

1905. McDougall, Alan, M.D., Ch.B.Viet., M.R.C.S., L.R.C.P.Lond., Medical

Director, The David Lewis Colony, Sandle Bridge, near Alderley
Edge, Cheshire.

1911. McDougall, William, M.A., M.B., B.C.Cantab., M.Sc.Vict., Foxcombe
Hill, Oxford.

1906. McDowall, Colin Francis Frederick, M.D., B.S.Durh., Ticehurst House,

Ticehurst.

1870. McDowall, Thomas W., M.D.Edin., L.R.C.S.E., Medical Superintendent,
Northumberland County Asylum, Morpeth. (PRESIDENT, 1897-8.)

1893. Macevoy, Henry John, B.A.(I)ouai), M.D., B.Sc.Loud., M.R.C.S.Eng.,

L.R.C.P.Lond., M.P.C., 19, Mowbray Road, Brondesbury, London,
N.W.

1895. Macfarlane, Neil M., M.D., C.M.Abcr., Medical Superintendent, Govern¬

ment Hospital, Thlotse Heights, Leribe, Basutoland, South Africa.
1883. Macfarlane, W. H., M.B. and Ch.B.Univ. of Melbourne, Medical Super¬
intendent, Hospital for the Insane, New Norfolk, Tasmauia.

1902. McGregor, John, M.B., Ch.B.Edin., Senior Assistant Medical Officer,

County Asylum, Bridgend, Glam.

1906. Macllraith, Alex. Robert MacIntyre, L.R.C.P.&S.Ediu., L.R.F.P.S.Glasg.,
Holly House, Rawtcustall, Lancs.

1905. Macllraith, William MacLaren, L.R.C.P. & S.Edin., L.R.F.P.S.Glasg.,

L. D.S., Holly House, Rawtenstall, Lancs.

1914. Mackey, Magnus Ross, M.D., Ch.B.Edin., Inverness District Asylum.
1899. McKelvey, Alexander Niel, L.R.C.P.&S.l., Costlcy House, Epsom,
Auckland, New Zealand.

1910. McKenzie, Ivy, M.A., B.Sc., M.B., Ch.B.Glasg., 10, Woodside Terrace,

Glasgow.

1911. Mackenzie, John Cosserat, M.B., Ch.B.Edin., County Mental Hospital,

Burntwood, near Lichfield.

1891. Mackenzie, Heury J., M.B., C.M.Edin., M.P.C., Assistant Medical Officer,
The Retreat, York.

1903. Mackenzie, Theodore Charles, M.D., Ch.B., F.R.C.P.Edin., M.P.C.,

Medical Superintendent, District Asylum, Inverness.

1914. Macleod, J. R., L.R.C.P.iS.Euin., L.R.F.P.S.Glasg., 7, Mayfield
Gardens, Edinburgh.

1904. Macnamara, Eric Darners, M.A.Camb., M.D., B.C., F.R.C.P.Lond., 54,

Welbeck Street, W.

1898. Macnnughton, George W. F., M.D., F.R.C.S.Edin., M.R.C.P.Lond.,

M. P.C., 33, Lower Belgrave Street, Eaton Square, London, S.W.
1914. Macueill, Celia Mary Colquhoun, M.B., Ch.B.Edin., Pathologist, North-

field, Prestonpans.

1910. MacPliail, Hector Duncan, M.A., M.D., Ch.B.Edin., Assistant Medical
Officer, City Asylum, Gosforth, Nswcastla-on-Tyne.

1882. Macphail, 8. Rutherford, M.D., C.M.Edin., Derby Borough Asylum,
Rowditch, Derby.

1896. Mucpherson, Charles, M.D.Glas., L.R.C.P.A.S., D.P.H.Edin., Deputy

Commissioner in Lunacy, 15, Rutland Square, Edinburgh.

1901. McRae, G. Douglas, M.D., C.M.Edin., F.R.C.P.Ed., Medical Super¬

intendent, District Asylum, Ayr, N.B.

1902. Macrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin., Bangour

Village, Dechmont, Liulithgowshirc.

1894. McWilliam, Alexander, M.A., M.B., C.M.Aber., Waterv.tl, Odiham,

Winchfield, Hants.

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Member* of the Association. xix

1915. Mansfold, Robert Ken tor, M.B., D.Ch.Dnb., Senior Assistant Medical
Officer, Denbigh As\lmn, North Wales.

1908. Mapotlier, Edward, M.l)., B.S.Lond., F.K.C.S.Eng., Assistant Medical
Officer, London County Asylum, Long-Grove, Epsom.

1903. Marnun, John, B.A., M.B., B.Ch.Dubl., Senior Assistant Medical

Officer, Second County Asylum, Gloucester.

1896. Marr, Hamilton C., M.l)., C.M.Glasg., F.R.F.P.8., M.P.C., Commis¬
sioner in Lunacy, 46, Murray field Avenue, Edinburgh. (Hon. Sec.
Scottish Division, 1907-1910.)

1913. Marshal), Robert, M.B., Cb.B.Glas., Assistant Medical Officer, Gartloch

Mental Hospital, Gartcosli, N.B.

1905. Marslmll, Robert Macnnb, M.l)., Cli.B.Glusg., M.P.C., 2, Clifton Place,
Glasgow.

1908. Martin, Henry Cooke, M.B., C'h.B.Ediu., Assistant Medical Officer,
Newport Borough Asylum, Caerleon.

1896. Martin, Janies Charles, L.R.C.S. & P.I., J.P., Assistant Medical Officer,
District Asylum, Lctterkcnny, Donegal.

1908. Martin, James Ernest, M.B., B.S.Loud., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, Loudon County Asylum, Long-Grove,
Epsom.

1907. Martin, Mary Edith, L.lt.C.P.AS.Edin., L.R.E.G.S.Gla*., L.S.A.Lond.,
M.P.C.Lond., Bail brook House, Bath.

1914. Martin, Samuel Edgar, M.B., H.Cli.Edin., Barrister-at-Law, Senior

Assistant Medical Officer, St. Andrew’s Hospital, Northampton.

1911. Martin, William Lewis, M.A., B.Sc., M.B., C.M.Edin., D.P.H., M.P.C.,
Dipl. Psych. (Certifying Physician in Lunacy, Edinburgh Parish
Council), 56, Bruntsfield Place, Edinburgh.

1911. Mathieson, James Moir, M.B., Ch.B.Aber., Assistant Medical Officer,
Wadsley Asylum, Sheffield.

1904. May, George Francis, M.D., C.M.McGill, L.S.A., Wiuterton Asylum,

Ferryhill, Durham.

1890. Menzies, William F., M.D.,B.Sc.Edin., M.R.C.P.Lond., Medical Superin¬

tendent, Stafford County Asylum, Cheddleton, near Leek.

1891. Mi rcier, Charles A., M.D.Loud., F.R.C.P., F.Ii.C.S.Eng., late Lecturer

on Insanity, Westminster Hospital; Moorcroft, Parkstone, Dorset.
(Secretary Educational Committee, 1893-1905. Chairman do.from
1905-12.) (President, 1908-9.)

1877. Merson, John, M.A., M.D., C.M.Aber., Medical Superintendent, Borough
Asylum, Hull.

1871. Mickle, William Julius, M.D., F.R.C.P.Lond., 69, Linden Gardens, Bayg-
water, W. (President, 1896-7.)

1893. Middlemass, James, M.A., M.D., C.M., B.Sc.Kdin., F.R.C.P., M.P.C.,
Medical Superintendent, Borough Asylum, ltyhopc, Sunderland.

1910. Middlemiss, James Ernest, M.R.C.S.Eng., L.R.C.P.Lond., Reginuld

House, 131, North Street, Leeds.

1883. Miles, G.-orge E., M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
British Empire Club, St. James’s Square, S.W.

1887. Miller, Alfred, M.B., B.Ch.Dubl., Medical Superintendent, Hattou
Asylum, Warwick. (Registrar since 1902.)

1904. Miller, James Webster, M.B., Cli.B.Aberd., Wonford House, Exeter.

1911. Miller, Margaret Mair, M.B., Ch.B.Edin., Assistant Medical Officer,

Northumberland County Asylum, Morpeth.

1912. Miller, Fleet-Surgeon Richard, R.N., M.B., B.Ch.Dubl., Medical Super¬

intendent, Naval Hospital, Great Yarmouth.

1893. Mills, John, M.B., B.Cii., Dipl. Ment. I)is., R.U.I., District Asylum,
Ballinasloe, Ireland.

1913. Milner, Ernest Arthur, M.B., C.M.Edin., Assistant Medical Officer, Royal

Albert Institution, Lancaster.

1881. Mitchell, Richard Blackwell, M.D., C.M.Edin., Medical Supt., Midlothian
District Asylum.

1911. Moll, Jan. Marins, Doc. in Arts and Med, Utrecht Univ., L.M.S.S.A.
Loud., M.P.C., West Koppics Asylum, Pretoria, S. Africa.

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xx Members of the Association.

1913. Molyueux, Benjamin Arthur, B.A., M.D., B.Ch.Dubl., County Asylum,

Gloucester.

1910. Monnington, Richard Caldicott, M.D., Ch.B., D.P.H.Ediu., Darenth

Industrial Colony, Dartford, Kent.

1914. Montgomery, Edwiu, F.R.C.S.I., L.R.C.l’.I. Dipl. Psych. Mnnch.,

Prestwick Asylum, Lancs.

1878. Moody, Sir James M., M.R.C.S.Eng., L.R.C.P.Edin., Medical Super¬
intendent, County Asylum, Cane Hill, Coulsdou, Surrey.

1911. Moon, George Bassett, L.RC.P. & S.Edin., L.R.F.P.S.Glasg., Assistant

Medical Officer, Surrey County Asylum, Nethernc.

1885. Moore, Edw. E., M.D., B.Ch.Dubl., M.P.C., Medical Superintendent,
District Asylum, Letterkenny, Ireland.

1899. Moore, Win. D., M.D., M.Ch.R.U.I., Medical Superintendent, Holloway
Sanatorium, Virginia Water, Surrey.

1914. Morres, Frederick, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Cane Hill Asylum, Coulsdon, Surrey.

1892. Morrison, Cuthbert S., L.R.C.P. A. S.Edin., Medical Superintendent,

County and City Asylum, Burghill, Hereford.

1896. Morton, W. B., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Wonford House, Exeter.

1896. Mott, F. W., M.D., B.S., F.R.C.P.Loud., LL.D.Edin., F.R.S., 25, Notting-
ham Place, W.

1896. Mould, Gilbert E., M.R.C.S., L.R.C.P.Lond., The Grange, Rotherham,

Yorks.

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Overdale, Whitefield,

Manchester.

1914. Moyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds, Crichton Royal
Institution, Dumfries.

1907. Mules, Bertha Mary, M.D., B.S.Durh., Court Hall, Kenton, S. Devon.
1911. Munro, William Thompson, M.D., C.B.Edin., Westgate, Friockkeim,
Forfarshire.

1911. Muncaster, Anna Lilian, M.B., B.Ch.Edin., Buchnall House, Stoke-on-
Trent.

1893. Murdoch, James William Aitkeu, M.B., C.M.Glusg., Medical Superin¬

tendent, Berks County Asylum, Wallingford.

1909. Myers, Charles Samuel, M.A., D.Sc., M.I)., B.C.Cantab., M.R.C.S.,
L.R.C.P.Lond., Great Shelford, Cambridgeshire.

1903. Navarra, Norman, M.R.C.S., L.R.C.P.Lond., City of London Mental
Hospital, near Dartford, Kent.

1910. Neill, Alexander W., M.D., Ch.B.Edin., Warneford Mental Hospital,
Oxford.

1903. Nelis, William F., M.D.Durh., L.R.C.P.Edin., L.R.F.P.S.Glasg., Medical
Superintendent, Newport Borough Asylum, Caerleon, Mon.

1873. Newington, H. Hayes. F.R.C.P.Edin , M.R.C.S.Eng., The Gables, Tice-
hurst, Sussex. (Chairman Parliamentary Committee, 1896-1904.)
(President, 1889.) (Treasurer since 1894.)

1909. Nicoll, James, M.D., C.M.Edin., D.P.H.Lond., Woodside, King’s Langley,
R.S.O., Herts.

1869. Nicolson, David, C. B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courts of Justice, Strand, W.C. (President, 1895-6.)

1893. Nobbs, Athelstane, M.D., C.M.Edin., Layton House, Putney, S.W.

1888. Nolan, Michael J., L.R.C.P.&S.I., M.P.C., Aledical Superintendent,
District Asylum, Downpatrick.

1913. Nolan, James No<5l Green, M.B., B.Ch., A.B.Dub., The Hospital, Hel-
lingly Asylum, Sussex.

1909. Norman, Hubert James, M.B., Ch.B., D.P.H.Edin., Assistant Medical
Officer, Camberwell House Asylum, S.E.

1885. Oakshott, Janies A., M.D., M.Ch.R.U.I., Medical Superintendent,
District Asylum, Waterford, Ireland.

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XXI

Members of the Association.

1903. O’Doherly, Patrick, 15.A., M.B., B.Ch.It.U.I., District Asylum,
Omagh.

1914. O’Flynn, Dominick Thomas, L.R.C.P. & S.I., Assistant Medical Officer,
County Asylum, Hanwell, Middlesex.

1901. Ogilvy, David, B.A., M.D., B.Ch.Dub., Medical Superintendent, London

County Asylum, Long Grove, Epsom, Surrey.

1910. Oldersleiw, George Francis, M.D., Ch.B.Liverp., D.P.H., M.P.C., Deputy

Medical Officer, H.M. Prison; and 3, Church ltoad, Walton,
Liveipool.

1911. Oliver, Norman H., M.lt.C.S., L.R.C.P.Lond., Charinouth Lodge, Rich¬

mond, Surrey.

1892. O’Marn, Francis, L.R.C.P.&S.I., District Asylum, Ennis, Ireland.

1886. O’Neill, Edward D., M.R.C.P.I., L.R.C.S.I., Medical Superintendent,
The Asylum, Limerick.

1863. Orange, William, C.B., M.D.Heidelb., F.R.C.I’.Loud., M.ll.C.S.Eng.,
11, Marina Court, Bexliill-on-Sea. (Pkksidhnt, 1883.)

1902. Orr, David, M.D., C.M.Edin., M.P.C., Pathologist, County Asylum,

Prcstwicli, Lanes.

1910. Orr, James H. C„ M.D., Cli.D.Edin., llosslyn Lee Asylum, Midlothian.
1899. Osburne, Cecil A. P., F.R.C.S., L.R.C.P.Edin., The Grove, Old Catton,
Norwich.

1914. Osburne, John C., M.B., B.Ch.Dubl., Assistant Medical Officer,Lindville,
Cork.

1890. Oswald, Landel R., M.B., C.M.Glasg., M.P.C., Physician Superin¬
tendent, Royal Asylum, Gartuaval, Glasgow.

1905. Paine, Frederick, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Clay bury Asylum,
Woodford Bridge, Essex.

1907. Parker, James, L.R.C.P.&S.I., St. Stephen’s Villa, North Strand,
Limerick.

1898. Parker, William Arnot, M.B., C.M.Glasg., M.P.C., Medical Super¬
intendent, Gartloch Asylum, Gurtcosh, N.B.

1898. Pasmore, Edwin Stephen, M.D., M.R.C.P.Lond., Chelsham House,

Chelsham, Surrey.

1899. Patrick, John, M.B., Ch.B., R.U.I., Medical Superintendent, Tyrone

Asylum, Ireland.

1892. Patterson, Arthur Edward, M.D., C.M.Aber., M.P.C., Senior Assistant

Medical Officer, City of London Asylum, Dnrtford.

1907. Pencliell, George Ernest, M.D., B.S.Loud., M.lt.C.S., L.R.C.P.Lond.,

M.P.C., Medical Superintendent, County Asylum, Newport, I. of W.

1903. Pearce, Francis H., M.A., M.B., B.C.Cnntab., M.R.C.S., L.R.C.P.Lond.,
M.P.C., Shirlett Sanatorium, Bruseley, Shropshire.

1910. Pearn, Oscar Phillips Napier, M.R.C.S., L.R.C. P., L.S.A.Lond., Assistant

Medical Officer, London County Asylum, Horton, Epsom.

1913. Penny, Robert Augustus Greenwood, M.R.C.S., L.R.C.P.Lond., Devon
County Asylum, Exminster.

1893. Perceval, Frank, M.lt.C.S.Eng., L.R.C.P.Lond., Medical Superintendent,

County Agylum, Prestwich, Manchester. Lancashire.

1911. Perdrau, Jean Rene, M.B., B.S.Lond., M.lt.C.S., L.R.C.P., Senior

Assistant Medical Officer and Pathologist, Dorset County Asylum,
Dorchester.

1911. Petrie, Alfred Alexander Webster, M.D., B.S.Lond., Ch.B., F.R.C.S.

Edin., Assistant Medical Officer, Epileptic Colony, Epsom.

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., 62, Upper Ken-
nington Lane, S.K.

1875. Philipson, Sir George Hare, M.A., M.D.Cantab., D.C.L., LL.D., F.lt.C.P.
Lond., 7, Eldon Square, Newcastle-ou-Tyne.

1908. Phillips, John George Porter,M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Reeident Physician and Superintendent, Bethlem Royal Hos]>ital.
Lambeth, S.E. (Secretary of Educational Committee eince

1912.)

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Digitized by

xxii Members of the Association.

1910. Phillips, John Robert Parry, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, City Asylum, Bristol.

190(5. Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬
tant Medical Officer, County Asylum, Abergavenny, Monmouth¬
shire.

1905. Phillips, Norman Routh, M.D.Brux., M.R.C.S., L.R.C.P.Lond., St.
Andrew’s Hospital, Northampton.

1891. Pierce, Bedford, M.D., F.R.C.P.Lond., Medical Superintendent, The
Retreat, York. (Ron. Secretary N. and M. Division 1900-8.)

1888. Pietersen, J. F. G., M.R.C.S., L.R.C.P.Lond., Ashwood House, Kingswin-

ford, near Dudley, Stafford.

1890. Planck. Charles, M. A.Cainb.jM.R.C.S.Kufr., L.R.C.P.Lond., Medical Super¬
intendent, Brighton County and Borough Asylum, Haywards Heath.

1912. Plummer, Edgar Curnow, M.R.C.S., L.R.C.P.Lond., Medieul Superinten¬

dent, Lavcrstock House, Salisbury.

1889. Pope, George Stevens, L.R.C.P.&S.Edin., L.R.F.P.S.Glasg., Medical

Superintendent, Somerset and Bath Asylum, “ Westfield,” near
Wells, Somerset.

1913. Potts, William A., M.A.Camb., M.D.Ediu.&Birm., M.R.C.S., L.R.C.P.

Loud., Consulting Medical Officer to the National Association for
the Feeble-minded, 118, Hagley Road, Birmingham.

1876. Powell, Evan, M.Il.C.S.Eng., L.S.A., Medieal Superintendent, Borough
Lunatic Asylum, Nottingham.

1910. Powell, James Farquharsou, M.R.C.S., L.R.C.P., D.P.H.Lond., Assistant
Medical Officer, The Asylum, Caterham, Surrey.

1912. Power, Pierce M. J., L.R.C.P. & S.I., Lieut. It.A.M.C.

1908. Prentice, Reginald Wickham, L.M.S.S.A.Lond., Beauworth Manor,
Alresford, Hants.

1904. Pringle, Archibald Douglas, M.B., Ch.B.Aberd., Government Asylum,
Pietermaritzburg, Natal, South Africa.

1901. Pugh, Robert, M.D., Ch.B.Edin., Medical Superintendent, Brecon and
Radnor Asylum, Talgarth, S. Wales.

1904. Race, John Percy, M.R.C.S., L.R.C.P., L.S.A.Lond., Winterton Asylum,
Ferryhill, Durham.

1913. Rac, Harry James, M.A., M.B., Ch.B.Aber., Kingseat Mental Hospital,
New Machar, Aberdeen.

1899. Rninsford, F. E„ M.D., B.A.Dubl., L.R.C.P.I., L.R.C.P.&S.E., Resident
Physician, Stewart Institute, Palmerston, co. Dublin.

1894. Rainbaut, Daniel F., M.A., M.l)., B.Ch.Dub., St. Andrews, Northampton.

1910. Rankin?, Surg. Roger Aiken, R.N., M.B., B.S., M.R.C.S., L.R.C.P.Lond.,

M.P.C.

1889. Raw, Nathan, M.D., B.S.Durh., L.S.Sc., F.R.C.S.Edin., M.R C.P.Lond.,
M.P.C., 66, Rodney Street, Liverpool.

1893. Rawes, William, M.D.Durh., F.R.C.S.Eng., Medical Superintendent, St.

Luke's Hospital, Old Street, London, E.C.

1870. Rayner,Henry,M.D.Aberd.,M.R.C.P.Edin., 16,Queen AnneStreet,London,
W. (Pbesidbnt, 1884.) (Oeneral Secretary, 1878-89.) ( Co-
Editor of Journal 1895-1911.)

1913. Read, Charles Stanford, M.B.Lond., M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Fisherton House, Salisbury.

1903. Read, George F., L.R.C.S.&P.Edin., Hospital for the Insane, New
Norfolk, Tasmania.

1899. Rediugton, John, F.R.C.S.&L.R.C.P.I., Portrane Asylum, Donabate,
Co. Dublin.

1911. Reeve, Ernest Frederick, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Senior Assistant Medical Officer, County Asylum, Ilainhill, Lancs.
1911. Reid, Daniel McKinley, M.D., Ch.B.Glasg., Roynl Asylum, Gartnaval,
Glasgow.

1910. Reid, William, M.A.St. And., M.B., Ch.B.Edin., Senior Assistant Medical
Officer, Burutwood Asylum, Lichfield.

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Members of the Association. xxiii

1887. Reid, William, M.D., C.M.Aberd., Physician Superintendent, Royal
Asylum, Aberdeen.

188C. Reviugton, George T., M.A., M.D., B.Ch.Dubl., M.P.C., Medical Superin.
tendent, Central Criminal Asylum, Du ml nun, Ireland.

1907. Reynolds, Ernest Septimus, H.Sc.Vict., M.D., F.R.C.P.Lond.,

M.R.C.S.Eng., 2, St. Peter’s Square, Manchester.

1899. Rice, David, M.D.Brux., M.R.C.S., L.R.C.P., D.P.II., Medical Super.

intendent.City Asylum, Hillesdon, Norwich.

1897. Richard, William J., M.A., M.B., Ch.M.GIasg., Medical Officer, Govan
Parochial Asylum, Merryfluts, Govan.

1899. Richards, John, M.B., C.M.Kdin., F.R.C.S.E., Medical Superintendent,

Joint Counties Asylum, Carmarthen.

1911. Roberts, Henry Howard, M.D., Ch.U.Kdin., D.P.II.Glasg., Ennerdalc,
Haddington, Scotland.

1914. Roberto, Ernest Theophilus, M.D., C.M.Edin., D.P.H.Camb., 129, Bath
Street, Glasgow.

1903. Roberts, Norcliffe, M.D., B.S.Durli., Senior Assistant Medical Officer,
Horton Asylum, near Epsom, Surrey.

1887. Robertson, Geo. M., M.D., C.M., K. R.C.P.Edin., M.P.C., Physician-Super¬

intendent, Royal Asylum, Morningside, Edinburgh.

1908. Robertson, George Dunlop, L.R.C.S.AP.Edin., Dipl. Psych., Assistant

Medical Officer, District Asylum, Hurtwood, Lanark.

1910. Robertson, Jane I., M.B., Ch.B.GIasg., c/o Masson, 31, Lacrosse Terrace,

Glasgow; and The Ivyleaf, Limavudy, Ireland.

1895. Robertson, William Ford, M.D., C.M.Edin., CO, Northumberland Street,
Edinburgh.

1900. Robinsou, Harry A., M.D., Ch.B.Vict., 66, West Derby Street, Liver¬

pool.

1911. Robson, Capt. Hubert Ainu Hirst, T.M.S., M.R.C.S., L.R.C.P.Loud.,

c/o Messrs. Urindlay, Groome, Bombay, Indin.

1914. Rodger, Murdoch Mann, M.D., Ch.B.Gla"., Second Assistant Medical
Officer, Cardiff Mental Hospital, Whitchurch, Glamorganshire.

1908. Rodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.II., Senior Medical
Officer, County Asylum, Winwick, Limes.

1908. Rolleston, Charles Frank, B.A., M.B., Ch.B.Dub., Assistant Medical
Officer, County of Loudon, Manor Asylum, Epsom.

1895. Rolleston, Lancelot W., M.B., B.S.Durli., Medical Superintendent, Mid¬
dlesex County Asylum, Napsbury, near St. Albans.

1899. Rorie, George Arthur, M.D., Ch.B.Edin., M.P.C., 163, Princes Street,
Dundee.

1888. Ross, Chisholm, M.D.Syd., M.B., C.M.Edin., 151, Macquarie Street,

Sydney, New South Wales.

1913. Ross,Derind Maxwell, M.B.,Cb.B.Edin.,Morningside Asylum, Edinburgh.
1910. Ross, Donald, M.B., Ch.B.Edin., Argyll and Bute Asylum, Lochgilphead.

1905. Ross, Sheila Margaret, M.D., Ch.B.Edin., Assistant Medical Officer of

Health, 42, C&rill Drive, Fallowfleld, Manchester.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Commissioner under
Ment. Defec. Act, Board of Control, 66, Victoria Street, West¬
minster, S.W.

1906. Rownn, Marriott Logon, B.A., M.D.R.U.I., Assistant Medical Officer,

Derby County Asylum, Mickleover.

1884. Rowe, Edmund L., L.R.C.P.AS.Edin., Medical Superintendent, Borough
Asylum, Ipswich.

1883. Rowland, E. D., M.B., C.M.Edin., The Public Hospital, George Town,
Demerarn, British Guiana.

1902. Rows, Richard Gundry, M.D.Loud., M.R.C.S., L.R.C.P.Loud., Patho¬
logist, County Asylum, Lancaster.

1877. Russell, Arthur P., M.B., C.M., M.R.C.P.Edin., The Lawn, Lincoln.

1912. Russell, John Ivison, M.B., Ch.B.GIasg., West Riding Asylum, Storthes

Hall, Kirkburton, Huddersfield.

1912. Rutherford, Cecil, M.B., B.Ch.Dubl., Assistant Medical Officer, Holloway
Sanatorium, Virginia Water, Surrey.

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xxiv Members of the Association.

1907. Rutherford, Henry Richard Charles, F.R.C.S.I., L.R.C.P.I., D.P.H., St.
Patrick’s Hospital, James's St., Dublin.

1890. Rutherford, James Mair, M.B., C.M.,F.R.C.P.Edin., M.P.C.,Brislington
House, Bristol.

1913. Ryan, Ernest Noel, B.A., M.D., B.Ch.Dub., E.A.M.C., 6th London
Field Ambulance (T.).

1902. Sail, Ernest Frederick, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬
intendent, Borough Asylum, Canterbury.

1908. Samuels, William Frederick, L.M.&L.S.Dubl., Medical Superintendent,

Central Asylum, Tangong, Rambutan, Federated Malay States.
1894. Sankey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medical
Licensee, Boreatton Park Licensed House, Baschurch, Salop.

* Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Rond, Oxford.
1873. Savage, Sir Oeo. H., M.D., F.R.C.P.Lond., 26, Devonshire Place, W.

(Late Editor of Journal.) (Pkesidbnt, 1886.)

1906. Scanlan, John J., L.R.C.P.&S.Edin., L.R.F.P.S.Glasg., D.P.H., 1, Castle
Court, Cornhill, E.C.

1896. Scott, James, M.B., C.M.Edin.. 98, Baron’s Court Road, West Kensing¬
ton, W.

1889. Scowcroft, Walter, M.R.C.S., L.R.C.P.I., Medical Superintendent, Royal
Lunatic Hospital, Cheadle, near Manchester.

1911. Scroope, Geoffrey, M.B., B.Ch.Dub., Assistant Medical Officer, Central

Asylum, Dundrum.

I860. Seccombe, George S., M.R.C.S., L.R.C.P.Lond., c/o Messrs. H. S. King
and Co., 65, Cornhill, E.C.

1906. Sephtou, Robert Poole, B.A.Cantab., M.R.C.S., L.R.C.P.Lond., County
Lunatic Asylum, Lancaster.

1912. Sere nt, John Noel, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical

•uperintendent, Newlands House, Tooting Bee Common, S.W.
t Secretary South-Eastern Division from 1913.)

1882. Seward, William J., M.B.Lond., M.R.C.S.Eng., 15, Chandos Avenue,
Oakleigh Park, N.

1013. Shand, George Ernest, M.B., Ch.B.Aberdeen, Cart., R.A.M.C. (S.R.).
1901. Shaw, B. Henry, M.B., B.Ch.R.U.l., Assistant Medical Officer, County
Asylum, Stafford.

1909. Shaw, Capt. William Samuel J., M.B., B.Ch.R.U.l., I.M.S., Superin¬

tendent, c/o Messrs. Grindlav & Co., 54, Parliament Street, London,
S.W.

1905. Shaw, Charles John, M.D., Cli.B., F.R.C.P.E., Medical Superintendent,
Royal Asylum, Montrose.

1904. Shaw, Patrick, L.R.C.P.&S.Edin., Senior Medical Officer, Hospital for

the Insane, Kew, Victoria, Australia.

1909. Shepherd, George Ferguson, F.R.C.S., L.R.C.P.Irel., D.P.H., 9, Ogle
Terrace, South Shields.

1900. Shera, John E. P., M.D.Brux., L.R.C.P.&S.Irel., Somerset County Asylum,

Wells, Somerset.

1912. Sheridan, Gerald Brinsley, M.B., B.Ch.R.U.l., Assistant Medical
Officer, Portrane Asylum, Dublin.

1914. Sherlock, Edward Burball, M.D., B.Sc., D.P.H.Lond., Medical Superin¬
tendent, Dareuth Industrial Colony, Dartford.

191-1. Shield, Hubert, M.B., B.S.Durb., Assistant Medical Officer, Gateshead
Borough Asylum, Stamington, Neweaetle-ou-Tyne.

1877. Shuttleworth, George E., B.A.Loud., M.D.Hcidelb., M.R.C.S. and L.S.A.
Loud., 8, Lancaster Place, Hampstead, N.W.

1901. Simpson, Alexander, M.A., M.D., C.M.Aber., Medical Superintendent,

County Asylum, Wiuwick, Newton-le-Willows, Lancashire.

1905. Simpson, Edward Swan, Al.D., Ch.B.Ediu., East Riding Asylum,

Beverley, Yorks.

1888. Sinclair, Eric, M.D., C.M.filasg., Inspector-General of Insane, Richmond
Terrace, Deuiaiu, Sydney, N.S.W.

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xxr

Members of the Association.

1891. Skeen, Jnines Humphry, M.B., Ch.M.Aber., Medical Superintendent,
Kirklands Asylum, Bothwcll.

1912. Skene, Leslie Henderson, M.B., Ch.B.Edin., Dipl. Psych., Assistant

Medical Officer, Hart wood Asylum, Lanarkshire.

1900. Skiuner, Ernest W., M.D., C.M.Ediu., J.P., Mountsfield, Itye, Sussex.
1914. Slnney, Clias. Newnlmm, M.R.C.8., L.lt.C.P.Lond., Deputy Medical

Officer, H.M. Prison Service, Avenue Lodge, Park hurst, I.W.

1901. Sluter, George N. O., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant

Medical Officer, Essex Countv Asylum, Brentwood.

1897. Smalley, Sir Herbert, M.D.Dnrh., M.K.C.S., L.R.C.P.Lond., Prison Com¬
mission. Home Office, Whitehall. S.W.

1910. Smith, Guyton Warwick, M.D.Lond., B.S.Durh., D.P.ll.Cantab.,

M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer, Middlesex
County Asylum, Tooting, S.W.

1905. Smith, George William, M.B.,Ch.B.Edin., Holloway Sanatorium, Virginia

Water, Surrey,

1907. Smith, Henry Watson, M.D., Ch.B.Abcrd., Medical Superintendent,
Lebanon Hospital for the Insane, Asfurujeh, near Beyrout,
Syria.

1899. Smith, John G., M.D., C.M.Ediu., Herts County Asylum, Hill End, St.
Albans, Herts.

1885. Smith, R. Percy, M.D., B.S., F.R.C.P.Lond., M.P.C., 86, Queen
Anne Street, Cavendish Square, W. ( General Secretary, 1896-7.
Chairman Educational Committee, 1899-1903.) (Pbbsidbnt,
1904-5.)

1913. Smith, Thomas Cyril, M.B., B.Ch.Edin., County Asylum, Gloucester.

1911. Smith, Thomas Waddelow, F.R.C.S., L.R.C.P.Lond., M.P.C., Assistant

Medical Officer, Wonford House, Exeter.

1884. Smith, W. Beattie, F.R.C.S.Edin., L.lt.C.P.Edin., M.P.C., 4, Collins

Street, Melbourne, Victoria.

1914. Smith, Walter H., B.A., M.I)., B.Ch.Dub., Senior Assistant Medical

Officer, County Asylum, Shrewsbury.

1903. Smith, William Maule A., M.D., Ch.B.Edin., M.R.C.P.Edin., M.P.C.,
98, Dagger Lane, West Bromwich.

1901. Smyth, Robt. 15., M.A., M.B., Ch.15.Dubl., Medical Superintendent,
County Asylum, Gloucester.

1899. Smyth, Walter S., M.B., B.Ch.R.U.I., Assistant Medical Officer, County
Asylum, Antrim.

1913. Somerville, Henry, B.Sc., M.R.C.S., L.R.C.P.Lond., F.C.S., Harrold,
Sharnbrook, Bedfordshire.

1885. Soutar, James Greig, M.B., C.M.Ediu., M.P.C., Medical Superintendent,

Barnwood House, Gloucester. (Pbbsidbnt, 1912-13.)

1906. Spark, Percy Charles, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

London County Asylum, Bansteud, Surrey.

1875. Spence, J. Beveridge, M.D., M.C.Q.U.I., Medical Superintendent, Burnt-
wood Asylum, near Lichfield. ( First Registrar, 1892-1899;
Chairman Parliamentary Committee, 1910-12.) (Pbbsidbnt,
1899-1900.)

1913. Spensley, Frank Oswold, M.B.C.S., L.R.C.P.Lond., Senior Medical

Officer, Darenth Asylum, Ilnrtford, Kent.

1891. Stansfield, T. E. K., M.B., C.M.Edin., Medical Superintendent, London
County Asylum, Bexley, Kent.

1901. Starkey, William, M.B., B.Ch.R.U.I., Assistant Medical Officer, Lanca¬
shire County Asylum, Prestwich, near Manchester.

1907. Steele, Patrick, M.D., Cb.B., M. 11.C.P.Edin., Assistant Medical Officer,

Bangour Village, Dechmont, Linlithgowshire.

1898. Steen, Robert H., M.D.Lond., Medical Superintendent, City of London
As\ luin. Stone, Hartford. (Hon. Sec. S.E. Division, i905-10.)

1914. Stephens, Harold Freizc, M.R.C.S.Lond., L.R.C.P.Eng., Karlswood

Asylum, Redhill.

1914. Stevenson, George Henderson, M.B., Ch.B.Edin., D.P.lI.Lond., Joyce
Green Hospital, Hartford, Kent.

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xxvi Members of the Association.

1012. Stevenson, William Edward, 51.B., B.S.Durh., Senior Assistant Medical
Officer, City a:nl Comity Asylum, Hereford.

1909. Steward, Sidney John, M.D., B.C.Cantab., M.U.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, Langtou Lodge, Farnoombe, Surrey.

1868. Stewart, James, B.A.Belf., F.R.C.P.Ed., L.R.C.S.I., Killydonuell, 28,
Glebe Road, Barnes, S.VV.

1913. Stewart, Ronald, M.B., Cb.B.Glasg., Gartlock Asylum, Gartcosb,

Glasgow.

1887. Stewart, Rothsay C., M.R.C.S.Eng., L.S.A.Lond., Medical Superinten¬
dent, County Asylum, Narborough, near Leicester.

1914. Stewart, Roy M., M.B., Cli.B.Edin., Assistant Medical Officer, County

Asylum, Prestwich.

1905. Stihvell, Henry Francis, L.R.C.P.&S.E., Hayes Park, Hayes, Middlesex.

1899. Stilwell, Reginald J., M.R.C.S., L.R.C.P.Lond., Moorcrolt House, Hil¬

lingdon, Middlesex.

1897. Stoddart, William Henry Butter, M.D., B.S., F.R.C.P.Lond., M.R.C.S.

Eng., M.P.C., 19, Cavendish Square, W. (Hon. Sec. Educational
Committee, 1908-1912.)

1909. Stokes, Frederick Ernest, M.B., Ch.B.Glasg., D.P.H.Cantab., Assistant
Medical Officer, Borough Asylum, Portsmouth.

1905. Strathearn, John, 51.D., Ch.B.Glasg., F.R.C.S.E., 23, Mngdalen Yard
Road, Dundee.

1903. Strntton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., 10, Hanover
Square, W.

1885. Street, C. T., M.R.C.S., L.R.C.P.Lond,, Hnydock Lodge, Ashton,

Newton-le-Willows, Lancashire.

1908. Stuart, Francis Arthur Knox, B. A. Cantab., L.S.A.Lond., Assistant Medical

Officer, West Sussex Asylum, Chichester.

1909. Stuart, Frederick J., M.R.C.S., L.R.C.P.Lond., Senior Assistant Mcdieul

Officer, Northampton County Asylum, Bcirywood.

1900. Sturrock, James Prain, M.A.St.And., M.D., C.M.Edin., 25, Palmcistou

Place, Edinburgh.

1886. Suffern, Alex. C., M.D., M.Ch.R.U.I., Medical Superintendent, ltubcrry

Hill Asylum, near Bromsgrove, VVorcestershire.

1894. Sullivan, William C., M.D., B.Ch.R.U.l., Hampton Criminal Lunatic
Asylum, South Leverton, Lincolnshire.

1910. Sutherland, Joseph Roderick, M.B., Ch.B.Glasg., M.R.C.S., L.R.C.P.,

D.P.H., County Sanatorium, Stonehouse, Lanarkshire.

1877. Swanson, George I., M.D.Edin., 23, St. Mary’s, York.

1908. Swift. Eric W. I)., M.B.Lond., Medical Superintendent, Government
Asylum, Bloemfontein.

1908. Tattersall, John, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
London County Asylum, Hauwell, W.

1910. Taylor, Arthur Loudoun, B.Sc., M.B., Ch.B., M.R.C.P.Edin., Senior

Assistant Medical Officer, Hawkhead Asylum, Paisley.

1897. Taylor, Frederic Ryott Percival, M.D., B.S.Lond., M.R.C.S.Eng.,

L. R.C.P.Lond., Medical Superintendent, East Sussex Asylum,
Hcllingly.

1908. Thomas, Joseph D., B.A., 51.B., B.C.Cantab., Nortliwoods House, Winter¬
bourne, Bristol.

1911. Thomas, William Rees, M.D., B.S.Lond., 5I.R.C.S., M.R.C.P.Lond.,

M. P.C., Mosside, Maghull, near Liverpool.

18S0. Thomson, David G., M.D., C.M.Edin., Medical Superintendent, County
Asylum, Thorpe, Norfolk. (President, 1914-15.)

1903. Thomson, Herbert Campbell, 51.D., F.R.C.P.Lond., Assist. Physician
Middlesex Hospital, 34, Queen Anne Street, W.

1905. Tidbury, Robert,51.D., 51.Ch. R.U.I., Heathlands, Foxhall Road, Ipswich.

1901. Tighe, John V. G. B., 51.B., B.Ch.R.U.l., Medical Superintendent,

Gateshead Mental Hospital, Stanuiugton, Northumberland.

1914, Tisdall, C. J., M.B., Ch.B., Crichton Royal Institution, Dumfries,

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Members of the Association. xxvii

1003. Tophain, J. Arthur, B.A.Cantab., M.U.C.S., L.R.C.P.Lond., County
Asylum, Cliurtlmni, Kent.

1896. Towusend, Arthur A. 1)., M.D., B.Ch.Birm., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical OiRcer, Hospital for Insane, Barmvood House,
Gloucester.

1904. Treadwell, Oliver Fereira Naylor, M.U.C.S.Eng., L.S.A.Loud., 102, Bel-
grave Road, S.W.

1903. Tredgold, Alfred F., M.R.C.S., L.R.C.P.Lond., 6, Dnpdune Crescent,
Guildford, Surrey.

1908. Tuach-MacKenzie, William, M.D., Cli.B.Aberd., Medical Superintendent,

Royal and District Asylums, Dundee.

1881. Tuke, Charles Molesworth, M.R.C.S.Eng., Chiswick House, Chiswick.

1888. Tuke, John Batty, M.D., C.M., F. R.C.P.Ediu., Resident Physician,

Situghton Hull, Edinburgh; Linden Lodge, Lonnhcad, Midlothian.
1886. Tuke, T. Seymour, M.A., M.B., B.Ch.Oxon., M.R.C.S.Eng., Chiswick
House, Chiswick, W.

1877. Turnbull, Adam Robert, M.B., C.M.Edin., Fife and Kinross District
Asylum, Cupar. (Hon. Secretary for Scottish Division, 1894-
1901.) (President-Elect, 1909-10.)

1906. Turnbull, Peter Mortimer, M.B., B.Ch.Aberd., Tooting Bee Asylum,
Tooting, S.W.

1909. Turnbull, Robert Cyril, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Essex County Asylum, Colchester.

1889. Turner, Alfred, M.D., C.M.Edin., Plymptou House, Plympton, S. Devon.
1906. Turner, Frank Douglas, M.B.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Officer, Royal Eastern Counties Institution, Colchester.

1890. Turner, John, M.B., C.M.Aberd., Medical Superintendent, Essex County

Asylum, Brentwood.

1878. Urquliart, Alex. Reid, M.D., LL.D.Edin., F.R.C.P.E. (retired and travel¬
ling), James Murray's lloyul Asylum, Perth. (Co-Editor of
Journal, 1894-1910.) (Hon. Sec. for Scottish Division, 1886-94.)
(President, 1898-9.)

1904. Yiuceut, George A., M.B., B.Ch.Edin.,Assistant Medical Superintendent,
St. Ann’s Asylum, Trinidad, B.W.l.

1894. Vincent, William James N„ M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Wndslev Asylum, near Sheffield.

1914. Vining, Charles Wilfred, M.D., BiS.Lond., M.R.C.P.Lond., D.P.H.,
Assistant Physician, Leeds General Infirmary, 40, Park Square,
Leeds.

1911. Waldron, Ethel Anuie, M.B., Ch.B.Birm., Dipl. Psych., Assistant Medical

Officer, West Riding Asylum, Wakefield.

1913. Walford, Harold R.S., M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Kent County Asylum, Banning Heath, Maidstone.

1914. Walker, Ernest Haines, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical

Officer, East Sussex County Asylum, Hellingly, Sussex.

1914. Walker, Robert Clive, M.B., Ch.B.Edin., West Riding Asylum, Menston,
near Leeds.

1908. Wallace, John Andrew Leslie, M.D., Ch.B.Edin., M.P.C., The Hospital,
Gladesville, Sydney, N.S.W.

1912. Wallace, Vivian, L.lt.C.P. & S.I., Assistant Medical Officer, Mullingar

District Asylum, Mullingur.

1889. Warnock, John, M.D., C.M., B.Sc.Edin., Medical Superintendent,
Abbasiyeh Asylum, nr. Cairo, Egypt.

1910. Waters, John Patrick F., B.A., M.B., Ch.B., R.U.I., Assistant Medical
Officer, County Asylum, Melton, Sufiolk.

1895. Waterston, Jane Elizabeth, M.l).Bru^L.R.C.P.I.,L.R.C.S.Edin., M.P.C.,

85, Parliament Street, Box 78, Wpe Town, South Africa.

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xxviii Members of the Association.

1902. Watson, Frederick, M.B., C.M.Edin., The Orange, Hast Finchley,

London,N.

1891 Watsou, George A., M.B., C.M.Edin., M.P.C., Lyons House, ltainhill,
Liverpool.

1908. Wutsou, H. Ferguson, M.D., Ch.B.OIns., L.R.C.P.&S.E., L.F.P.S.Qlas.,
Northcote, Edinburgh Road, Perth.

1885. Watson, William Riddell, L.R.C.S.& P.Edin., 3, Tufnell Hou-c, Anson
Road, Tufnell Park, N.

1910. Watson, William Scott, M.D., Ch.B.Edin., c/o Mental Hospital Dept.,

Government Buildings, Wellington, New Zealand.

1911. White, Edward Barton C., M.R.C.S., L.R.C.P.Lond., Senior Assistant

Medical Officer, Cardiff City Mental Hospital, Whitchurch.

1884. White, Ernest William, M.B.Loud., M.R.C.P.Lond., Betley House, nr.

Shrewsbury. ( Hon. Sec. South-Eastern Division, 1897-1900.)
( Chairman Parliamentary Committee, 1904-7.) (Pbkbidbnt
1903-4.)

1905. Whittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond.,
Downford, Montpelier Road, Brighton.

1889. Whitwell, James Richard, M.B., C.M.Edin., Medical Superintendent,
Suffolk County Asylum, Melton Woodbridge.

1903. Wigan, Charles Arthur, M.D.Durh., M.ll.C.S.Eng., L.S.A.Lond., Deep-

dene, Portishead, Somerset.

1883. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Springfield House, Wins-
combe, Somerset. (Pbbsidxkt, 1902-3.)

1913. Wilkins, William Dougins, M.B., Ch.B. Viet., M.R.C.S., L.R.C.P.Lond.,

Assistant Medical Officer, Winwick Asylum, Warrington.

1900. Wilkinson, H. B., M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer
Plymouth Borough Asylum, Blackadon, Ivybridge, South Devon.
1887. Will, John Kennedy, M.A., M.D., C.M.Aberd., M.P.C., Bethnal House,
Cambridge Road, N.E.

1914. Williams, Charles, L.R.C.P. AS.Edin., L.S.A.Lond., Assistant Medical

Officer, The Warneford, Oxford.

1907. Williams, Charles E. C., M.A., M.D., B.Ch.Dubl., Assistant Medical
Officer, Hollowny Sanatorium, Virginia Water, Surrey; Greystones,
Canford Cliff, Bournemouth.

1905. Williams, David John, M.R.C.S., L.R.C.P.Lond.,Medical Superintendent,
The Asylum, Kingston, Jamaica.

1912. Wilson, Samuel Alexander Kiuneir, M.A., M.D., B.Sc.Ediu., M.R.C.P.

Lond., Registrar, National Hospital, Queen’s Square, 14, Harley
Street, W.

1897. Winder, W. H., M.R.C.S., L.R.C.P.Lond., D.P.H.Cautab., Deputy
Medical Officer, H.M. Convict Prison, Aylesbury.

1875. Winslow, Henry Forbes, M.D.Lond., M.R.C.P.Lond., M.R.C.S.Eng.,
1G4, Marine Parade, Brighton.

1899. Wolseley-Lewis, Herbert, M.D Brtix., F.R.C.S.Eng., L.R.C.P.Lond.,

Medical Superintendent, Kent County Asylum, Harming Heath,
Maidstone. ( Secretary Parliamentary Committee, 1907-12. Chair¬
man since 1912.)

1869. Wood, T. Outtersou, M.D.Durh., M.R.C.P.Loud., F.R.C.P., F.R.C.S.

Kdin., 7, Abbey Crescent, Torquay. (Pbbsidbnt, 1905-6.)

1912. Woods, James Cowan, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, The Priory, ltoehampton.

1885. Woods, J. F., M.D.Durh., M.R.C.S.Eng., 7, Harley Street, Cavendish

Square, W.

1912. Wootton, John Charles,M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical
Officer, Cane Hill Asylum, Surrey.

1900. Worth, Reginald, M.B., B.S.Durb., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Middlesex Asylum, Tooting, S.W.

1862. Yellowlees, David, LL.D.01as., M.D.Edin., F.R.F.P.S.Glasg., 6, Albert
Gate, Dowan Hill, (llasgow. (Pbbbidbht, 1890.)

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PRINCETON UNIVERSITY

XXIX

Members of the Association.

1014. Yellowlees, Henry, M.H., Ch.B.Glns., Craig Houie, Moruingside Drive,
Edinburgh.

1910. Younger, Edward George, M.D.Brux., M.R.C.P., M.R.C.S., L.S.A.Lond.,
D.P.H., Physician to the Finsbury Dispensary, 2, Mecklenburgh
Square, W.C.

Ordinary Members . 079

Honorary Members ... 34

Corresponding Members . 18

Total. 731

Members are particularly requested to send changes of address, etc., to Dr.

M. Abdy Collins, the Honorary General Secretary, 11, Chandos Street,
Cavendish Square, London, IF., and in duplicate to the Printers of the
Journal, Messrs. Adlard and Son, 23, Bartholomew Close, London,
E.C.

OBITUARY.

Members.

1800. Alexander, Robert Reid, M.D., C.M.Aber., 38, Glenloeh Road, Haverstock
Hill, N.W.

1909. Crowther, Sydney Nelson, M.R.C.S., L.R.C.P.Lond., Medical Superin¬
tendent-elect, Netherue Comity Asylum, Surrey ( killed tit action).
1899. Douelan, Thomas O’Conor, L.R C.P. A S.I., Middlesex County Asylum,
Napsbury, near St. Albans, Herts.

1890. Gaudin, Francis Neel, M.R.C.S.Kng., L.S.A., M.P.C., Medical Superin¬

tendent, The Grove, St. Lawrence, Jersey.

1897. Mumby, Bonner Harris, M.D.Aber., D.P.H.Cantab., Medical Superin¬
tendent, Borough Asylum, Portsmouth.

1880. Neil, James, M.D., C.M.Aberd., M.P.C., Medical Superintendent,
Warneford Asylum, Oxford.

1875. Newington, Alexander, M.B.Camb., M.R.C.S.Kng., Woodlands, Tice-
burst.

1891. Shaw, Harold B., B.A., M.B., B.C., D.P.H.Cumb., Medical Super¬

intendent, Isle of Wight County Asylum, Whitccroft, Newport, Isle
of Wight.

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PRINCETON UNIVERSITY

XXX

Digitized by

List of those who have passed the Examination for the Certificate of Eflieiency
in Psychological Medicine, entitling them to append M.P.C. (Med.-l’sych.
Certif.) to their names.

Adams, J. Barfield.

Adamson, Robert 0.

Aclkins, Percy, R.

Ainley, Fred Shaw.

Ainslie, William.

Alcoek, B. J.

Alexander, Edward H.
Anderson, A. W.

Anderson, Bruce Arnold.
Anderson, John.

Andriezeu, W.

Apthorp, F. W.

Armour, E. F.

Attegalle, J. W. S.

Aveline, H. T. S.

Ballantyne, Harold S.

Barbour, William.

Barker, Alfred James tilauville.
Bashford, Ernest Francis.
Bazalgette, S.

Begg, William.

Bel ben, F.

Bird, James Brown.

Blackford, J. Vincent.

Black, E. J.

Black, Robert S.

Black, Victor.

Blackwood, John.

Blandford, Henry E.

7 Bond, C. Hubert.

Bond, R. St. O. S.

Bowlan, Marcus M.

Boyd, James Patou.

13 Boyd, William
Bradley, J. T.

Bristowe, Hubert Carpenter.
Brodie, Robert C.

Brough, C.

Browu, William.

Browne, Hy. E.

Bruce, John.

Bruce, Lewis C.

Brush, S. C.

Bulloch, William.

Calvert, William Dobrce.
Cameron, James.

Campbell, Alex Keith.

Campbell, Allred W.

Campbell, Peter.

Carmichael, W. J.

Carrutbers, Samuel VV.

Carter, Arthur W.

Chambers, James.

Chambers, W. 1).

Chapman, H. C.

Christie, William.

Clarke, Robert H.

Clayton, Frank Herbert A.
Clayton, Thomas M.

Clinch, Thomas Alduus.

Coles, Richard A.

Collie, Frank Lang.

Collier, Joseph Henry.

Couolly, Richard M.
Conry, John.

Cook, William Stewart.
Cooper, Alfred J. S.

Cope, George Patrick.
Corner, Harry.

Cotton, William.

Coupcr, Sinclair.

Cowan, John J.

Cowie, C. G.

Cowie, George.

Cowper, John.

Cox, Walter H.

8 Craig, M.

Cram, John.

Crills, G. H.

Cross, Edward John.
Cruickshauk, George.
Cullen, George M.
Cunningham, James F.
Ualgetty, Arthur B.
Davidson, Andrew.
Davidson, William.

6 Dawson, W. R.

De Silva, W. H.

11 Devine, H.

Distin, Howard.

Dixon, J. F.

Donald, Win. I). D.
Donaldson, R. L. S.
Donelan, James O'Conor.
Douglas, A. R.

Downey, Augustine.
Drummond, Russell J.
Eager, Richard.

Karnes, Henry Martyn.
Earls, James H.

East, VV. Norwood.
Easterbrook, Charles C.
Eden, Richard A. S.
Edgerley, S.

Edwards, Alex. H.

Elkins, Frank A.

Ellis, Clarence J.

English, Edgar.

Eustace, J. N.

Eustace, Henry Marcus.
Evans, P. C.

Ewan, John A.

Ezard, Ed. W.

Falconer, A. R.

Falconer, James F.
Farquharson, Win. Fredk.
Fennings, A. A.

Ferguson, Robert.

Findlay, G. Landsborough.
Fitzgerald, Gerald.

Fleck, David.

Fortune, J.

Fox, F. G. T.

Fraser, Donald Allan.
Fraser, Thomas.

Frederick, Herbert John.

Google

Original from

PRINCETON UNIVERSITY

XXXI

Gage, J. M.

Gaud in. Francis Neel.

Gawn, Ernest K.

(reinmell, William.

Geuney, Fred. S.

Gibb, H. J.

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilmonr, John 11.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Gostwyck, C. H. G.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Wemyss.

Grant, Lacklan.

Gray, Alex. C. E.

Gray, Theodoro G.

Griffiths, Edward H.

Haldane, J. R.

Hall, Harry Baker.

Halsted, H. C.

Hoslam, W. A.

Haslett, William John Handheld
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hennan, George.

Hewat, Matthew L.

Hewitt, D. Walker.

Hicks, John A., jun.

Hi tellings, Robert.

Holmes, William.

Horton, James Henry.

Hotchkis, R. D.

Howden, Robert.

Hughes, Robert.

Hunter, G. T. C.

Hutchinson, P. J.

2 Hyslop, Tlios. B.

Ingram, Peter R.

Jeffery, G. R.

Jagannadhan, Annie W.
Johnston, John M.

Johnstone, Emma M.

Keith, W. Brooks
Kelly, Francis.

Kelso, Alexander.

Kelson, W. H.

Ker, Claude B.

Kerr, Alexander L.

Keyt, Frederick.

King, David Burty.

King, Frederick Truby.

Luiug, C. A. Barclay.

Laing, J. H. W.

Law, Thomns Bryden.

Lceper, Richard R.

Leslie, R. Murray.

Livesay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Lothian, Nonnuii V. C.

Low, Alexander.

McAllum, Stewart.

Macdonald, David.

Macdonald, G. B. Douglas.
Macdonald, John.

Macdonald, W. F.

Maeevoy, Henry John.
McGregor, George.

Maclnnes, Ian Lament.
Mackenzie, Henry J.

Mackenzie, John Cumming.
Mackenzie, T. C.

Mackenzie, William H.
Mackenzie, Williuin L.

Mackie, George.

McLean, H. J.

Macmillan, John.

5 Mncnaughton, Geo. W. F.
Macnoice, J. G.

Macpherson, John.

Macvenn, Donald A.

Mallannnh, Srecunguln.

Marr, Hamilton C.

Marsh, Ernest L.

Marshall, R. M.

Martin, A. A.

Martin, A. J.

Martin, M. E.

Martin, Wm. Lewis.

Masson, James.

McDowall, Colin.

Mcikle, T. Gotdou.

Melville, Henry B.

Middlemass, James.

Miller, R.

Miller, R. H.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Moll, J. M.

Monteith, James.

Moore, Edward Erskiuc.

I Mortimer, John Desmond Ernest
Muuro, M.

Murison, Cecil C.

Murison, T. D.

Myers, J. W.

Nail - , Charles R.

Nairn, Robert.

Neil, James.

Nixon, John Clarke.

Nolan, J. N. G.

Nolan, Michael James.

Norton, Everitt E.

Oldersliaw, G. F.

Orr, David.

Orr, James.

Orr, J. Fraser.

Oswald, Latidel R.

Owen, Corbet W.

Paget, A. J. M.

Parker, William A.

Parry, Charles P.

Patterson, Arthur Edward.
Patton, Wnlter S.

Paul, William Moncrief.
Pcachell, G. E.

Pearce, Francis H.

Pearre, Walter.

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PRINCETON UNIVERSITY

XXX11

Digitized by

Penfold, William James.
IVrdrau, J. A.

Philip, James Farqubar.
Philip, William Marshall.
12Phillips, J. G. Porter.
Phillips. J. K. P.

Pieris, William C.
Pilkington, Frederick W.
Pitcairn, John James.
Porter, Charles.

Powell, James F.

Price, Arthur.

Priug, Horace Reginald.
Rainy, Harry, M.A.

Ralph, Richard M.

Rankine, R. A.

Rannie, James.

4 Raw, Nathan.

Reid, Matthew A.

Renton, Robert.

Rice, P. J.

Rigden, Alan.

Ritchie, Thomas Morton.
Rivers, W. H. R.

Roberts, Ernest T.
Robertson, G. D.

8 Robertson, G. M.

Robson, Francis Wm. Hope.
Rorie, George A.

Rose, Andrew.

Ross, D. Maxwell.

Ross, Donald.

Rowand, Andrew.

Rudall, James Ferdinand.
Rust, James.

Rust, Montague.
lORutherford, J. M.

Sawyer, Jns. E. H.

Scanlon, M. P.

Scott, F. Riddle.

Scott, George Brebner.
Scott, J. Walter.

Scott, William T.

Seuwright, H. G.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skae, F. M. T.

Skeen, George.

Skeen, James H.

Slater, William Arnison.
Slattery, J. B.

Smith, Percy.

Smith, T. Waddclow
Smith, William Maule.

Smyth, William Johnson.
Snowball, Thomas.

Soutar, James G.

Sproat, J. H.

Stanley, John Douglas.

Staveley, William Heury Charles.
Steel, John.

Stephen, George.

Stewart, William Day.

Stoddart, John.

9 Stoddart, William Hy. B.
Strongman, Lucia.

Strong, D. R. T.

Stuart, William James.

Symes, G. D.

Taylor, W. J.

14Tbomas, W. Rees.

Thompson, A. D.

Thompson, George Matthew.
Thomson, A. M.

Thomson, Eric.

Thomson, George Felix.

Thomson, James H.

Thorpe, Arnold E.

Trotter, Robert Samuel.

Turner, W. A.

Umney, W. F.

Vining, C. W.

Walker, James.

Wallace, J. A. L.

Wallace, W. T.

Warde, Wilfred B.

Waters, John.

Waterstou, Jane Elizabeth.
Watson, George A.

Welsh, David A.

West, J. T.

White, Hill Wilson.

Whitwell, Robert It. H.
Wickham, Gilbert Henry.

Will, John Kennedy.

Williams, 1). J.

Williamson. A. Maxwell.

4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, David James.

Wright, Alexander, W. 0
Yeates, Thomas.

Yeoman, John B.

Young, D. P.

Younger, Henry J.

Zimmer, Carl ltaymoud.

1 To whom the Gaskell Prize (1887) was awarded.

2 To whom the Gaskell Prize (1889) was awarded.

3 To whom the Gaskell Prize (1890) was awarded.

4 To whom the Gaskell Prize (1892) was awarded.
6 To whom the Gaskell Prize (1895) was awarded.

6 To whom the Gaskell Prize (1896) was awarded.

7 To whom the Gaskell Prize (1897) was awarded.

8 To whom the Gaskell Prize (1900) was awarded.

9 To whom the Gaskell Prize (1901) was awarded.

10 To whom the Gaskell Prize (1906) was awarded.

11 To whom the Gaskell Prize (1909) was awarded.

12 To whom the Gaskell Prize (1911) was awarded.

13 To whom the Gaskell Prize (1912) was awarded.

14 To whom the Gaskell Prize (1913) was awarded.

Google

Original from

PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

[,Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]

No. 252 [ N z:\:r] JANUARY, 1915. vol. lxi.

Part I.—Original Articles.

The Position of Psychiatry and the Role of General
Hospitals in its Improvement. The Introductory
Address delivered at the Opening of the Winter Session,
1914—1 5, at the Middlesex Hospital on October ist, 1914.
By C. Hubert Bond, D.Sc., M.D.Edin., M.R.C.P.Lond.,
Commissioner of the Board of Control, and Emeritus
Lecturer in Psychiatry at Middlesex Hospital Medical
School.

Gentlemen, — In the first place I desire to express my
thanks to the council of the medical school for the honour they
have done me in asking me to give the introductory address
which is customary at the opening of each of our winter sessions.
That I particularly esteem the privilege will be readily appre¬
ciated when I remind you of where we are gathered, and that
this is the first function which has taken place in the Bland-
Sutton Institute of Pathology, which, with its laboratory,
lecture theatre, and museum, will always be a monument to Sir
John Bland-Sutton’s princely munificence, to his affection for
the hospital and medical school, to his devotion to science,
and to his belief in her power to relieve suffering humanity.
And who will dare attempt to gauge the direct and indirect
influence of this institute? Sir John’s catholicity is well known,
and I feel assured of his sympathy when I venture to hope
that psychiatry, which is the branch of medicine in which my
LXI. I

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PRINCETON UNIVERSITY

2 THE POSITION OF PSYCHIATRY, [jail.,

interests are specially centred, will have its fair share of the
blessings that doubtless will be showered from this institute.

The pleasure of our gathering is, however, marred in one
particular, for we have to lament the absence of His Serene
Highness, Prince Alexander of Teck, whose active interest
in all that pertains to the welfare of the hospital and medical
school is so deeply appreciated, and whose presence we should
have enjoyed to-day were it not that his military duties have
made it impossible.

Few academic sessions can ever have opened amidst such
momentous events as does the present one ; and whatever
diffidence I felt in accepting the responsibility of this year’s
address has not been diminished by the fact that I am conscious
there are other members of the school’s staff who would in all
likelihood have chosen a theme more in consonance with the
stirring events with which our thoughts are thrilled : indeed,
realising that such a course would probably prove the more
acceptable, I did make an attempt to recast the draft of my
remarks, but, not unmindful of Pliny’s injunction to the cobbler,
and wishing to eschew anything like an “ultracrepidarian” repu¬
tation, I have harked back to my original purpose, which was
to bring before your notice (a) the present position in which
psychiatry stands; (b) the essential cause of this position ; and
(c) to endeavour to convince you that general hospitals—more
particularly those to which medical schools are attached—can,
if they choose, effect a material improvement therein.

However, before entering upon the subject-matter of my
discourse, it appears to me not only fitting, but to be a duty,
to emphasise the sincere sympathy which I am confident each
one of us most deeply feels with those schools, colleges and
seats of learning, whose important educational functions have
been temporarily suspended owing to their position in the
theatre of military operations, or by any indirect effects of the
war. Especially do those feelings arise when we think of
ruined Louvain. It was some consolation to read that, in
connection with the University of Oxford, a strong committee
has been formed with the intention of offering hospitality to
the professors of Louvain and their families, and that a similar
welcome to both teachers and students is being extended by
the Universities of Cambridge and London. May we not
hope that our several universities and other teaching centres

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PRINCETON UNIVERSITY

I9I5-]

BY C. HUBERT BOND, D.SC.

will find some means of offering, not only their educational
machinery, but also their residential facilities to every Conti¬
nental student who, robbed of corresponding opportunities in
his own university, is able to take advantage of them ? Such
action on our part would in some instances be no more than
the satisfaction of an actual debt we owe them, and it is not
unreasonable to hope that in the case of every foreign student
so received the indirect influence of a period of study in one
of our colleges would be to the ultimate advantage of this
country.

It may also be not inopportune to here record our pride at
the whole-hearted and enthusiastic response which our univer¬
sities and colleges have made to the call for recruits. Of
observing these men’s eager enthusiasm it happens that a
specially favourable opportunity was afforded me, by reason of
the fact that one of the chief recruiting centres for this class
was in the building in which the offices of the Board of
Control are situated. It is a satisfaction to know that in the
case of those who have not completed their college curriculum
steps have been taken to ensure that their academic careers
will not be jeopardised by their absence on military duties.
On the contrary, may we not take it as certain that it will
tend to broaden their outlook of life and sharpen their powers
of appreciation ?

(A) Psychiatry the Cinderella oe Medicine.

Psychiatry, or by whatever other term you prefer to denote
the study and treatment of mental diseases, has sometimes
been characterised as the Cinderella of general medicine ; that
is to say, it has been alleged to be a branch which, compared
with other medical subjects, lacks sustaining interest, and the
study of which is apt to side-track its devotees into blind
alleys where their scientific enthusiasm is chilled, and their
legitimate aspirations to maintain an honourable position for
themselves are disappointed. Now, while I can emphatically
assert that any such description is very one-sided, and wholly
untrue as respects the first part of the allegation, there is in
its second part a modicum of truth which has, I believe,
barred the way to many a young medical man who would
otherwise have maintained his initial interest in the subject both

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PRINCETON UNIVERSITY

4 THE POSITION OF PSYCHIATRY, [Jan.,

to its and his own advantage, and which therefore had better
be clearly understood.

(a) Wherein the Statement is not True.

To refute the allegation that the study of psychiatry in any
way lacks sustaining interest is not difficult. What student
or medical man, possessed of his normal share of scientific
inquisitiveness, has ever filled a resident post iiv an institution
for the insane in which, affiliated to a medical school, teaching
and research work go hand in hand with its administration,
and has come away imbued with any such notion ? I have
never met him. On the contrary, if really necessary, it would
be an easy task to demonstrate that the subject possesses an
absorbing and, indeed, transcendent interest ; that in its
compass—not easy to define—its borders insensibly merge
into those of other departments of general medicine ; that in
not a single medical or surgical case can the mental side of
the patient be safely ignored ; that the truth of this last fact—
often forgotten—not infrequently comes home to the medical
man in attendance with startling and unpleasant force ; that
without a sound knowledge of at least the elements of
psychiatry such circumstances may cause him much embarrass¬
ment ; and, lastly, that, to the medical man who is tempted to
dive below the mere surface of the subject, there is a wealth of
problems, each well deserving a life’s devotion, whose non¬
solution impedes successful treatment, but whose elucidation
may with confidence be expected to restore to a normal life
many of those afflicted with the direst of human calamities,
who, in the light, or rather the obscurity, of existing knowledge,
are now too often doomed to premature death, or life-long
segregation from their friends. And, of still greater moment
to the public, there is good ground for believing that, with the
removal of some of the perplexities with which the subject is
at present strewn, not only will many a man and woman be
able to ward off the necessity of such segregation, but also will
the path of many a one be rendered smooth where now, by
reason of the traveller’s neuropathic oddities and obsessions, it
is thorny, and often pursued only at a cost of much mental
pain. The accomplishment of all this by no means spells a
fresh goal. The problems which now await solution are, for

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PRINCETON UNIVERSITY

IQI5-]

BY C. HUBERT BOND, D.SC.

the most part, fresh hill-points which have come into view
when the summit of others has been attained by the indefatigable
labours of certain of our predecessors and confreres in the
specialty. That they have been all too few and often ill
requited is true enough, but in their accumulated observations
they have left a heritage which is a veritable treasure house.
In no other branch of medicine is the harvest whiter than in
psychiatry, and I fain would persuade some of you who are
about to enter the medical profession to come in and gather it.

(b) The Allegation True in Two Counts.

Wherein then, you will ask, is psychiatry even remotely
deserving to be dubbed a Cinderella? The epithet is deserved,

I fear, as respects two counts: (i) The unpopularity of the
asylum medical service, and (2) the manner in which psychiatry’s
claims are overlooked by philanthropists. Both are, in my
opinion, dependent primarily on the same cause.

(I) The unpopularity of medical work in asylums. —The first
and probably most obvious count is the undeniable reluctance
of young medical men and women to enter the specialty at all,
or, at any rate, to enter it with a view to applying themselves
seriously to it as their life’s work. Certain it is that at the
present moment public asylums—even those most favourably
situated—find it increasingly hard to obtain suitable candidates
from which to fill vacancies in the junior ranks of their medical
staffs ; so acute has been the difficulty that, at a large asylum
in a medical staff comprising a superintendent and six assis¬
tants, I have known as many as three of the latter positions
to be filled at the same time by locum-tenents—in other
words, by men between whom and the institution the link is so
small that it can be severed at a week’s notice. No one will
deny that such a position of affairs is a menace to the present
and future welfare of any such institution; it is highly desirable
that this should be realised by the public in whose hands, mainly
through their municipal representatives, the remedy largely lies.

(i) Causes of this unpopularity. —The task of exposing and
grappling with the difficulty has within the last three years been
undertaken by a committee of the Medico-Psychological Associa¬
tion, and is set forth in an admirable and comprehensive report
which will be found in this month’s^) number of the fournalof

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Mental Science. This report is all the more weighty, and
should the more commend itself to the public, because, whilst
nowhere in it arc the interests of the patients subordinated to
those of the medical men, there is, with a due claim for the
pecuniary advancement of some of the latter, a pari passu
demand for increased opportunities for adequate initial training
and future study and research. The subject is also dealt with
at some length in the Sixty-eighth Report (pp. 40, 41) of the
Commissioners in Lunacy, which was published this year.
No doubt the paucity of applications for these by no means
unimportant and not ill-paid asylum posts is to some extent
due to the large increase in the number of available public
health appointments (whether as medical officers of health,
school medical officers, or tuberculosis officers), to the passing
of the Insurance Act, and to the improvements effected in the
medical departments of the Royal Navy and the Army.

But the difficulty is of too long standing to be explained by
those three factors, though it is they, doubtless, that have
rendered it acute ; otherwise it might be left to right itself on
the principle of supply and demand. Nor, while refraining
from any expression of opinion as to the merits or demerits of
the suggestion that public asylums (which are at present
managed by local authorities) should all be linked up to form
one common service, do I believe that the adoption of that
policy would of necessity render asylum work more popular as
a career for medical men.

The crux of the situation lies in the fact that with the
gradual increase in the number of medical appointments in the
specialty, consequent upon the steady growth in the number of
public asylums, the proportion, which the number of posts
justly regarded as “plums”—offering an assured, independent,
and satisfactorily remunerated position—bears to the number
of subordinate and hitherto far from assured positions, has
unfortunately become less and less. Time was when most
public asylums were small institutions, medically staffed by a
superintendent and one assistant: the latter’s status was
comparable to that of a house physician ; quite equitably only
bachelor’s quarters were provided for him ; he was looked upon
as a bird of passage, and as such regarded himself. Additions
have, however, been made so persistently to asylums that now, out
of the 97 existing county and borough asylums in England

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and Wales—providing between them more than 300 medical
posts—no less than 40 contain over 1000 patients, and of these
in about 14 the number is more than 2000, while only 16
contain less than 500 patients. Manifestly, with such a great
augmentation in the size of asylums, the number of medical
officers who, for the safety of the institution, must be regarded
as permanent officials has largely increased, but in the mean¬
while custom has—I venture to suggest, needlessly and unwisely
—decreed that the position of those officials should remain
much as it was when asylums were small units ; so that, while
in former days 50 per cent, of asylum medical appointments
were coveted and assured positions, the same can now be said
of scarcely 30 per cent. In other words, the junior’s aphorism
that “the assistant medical officer of to-day is the superintendent
of to-morrow ” is lamentably untrue. Were it always a fact,
the present shortage in applicants would never have arisen ;
but to express the truth we cannot go farther than to say
that the “ superintendent of to-day is the assistant medical
officer of yesterday.”

(ii) To overcome the unpopularity. —But if I have hitherto
painted to you the darker side of asylum service, I am entitled
to show you its brighter aspect, and it has one. In the first
place, the disabilities of the service, some of which I have
indicated, are recognised and admitted as evils. That is a
great step, and it is gratifying to add that, not only have several
local authorities substantially mitigated them by granting :

(a) Increases in salaries, and the provision of separate houses
for assistant medical officers , lending hope to our being within
measurable distance of seeing the principle accepted that no
resident male official in our asylums, whose services it is desired
in the interests of the institution to retain over a series of years,
shall be debarred either from marriage or from other social
advantages, including a reasonable independence of position ;
but also a healthy spirit has arisen calling for evidence of
greater scientific training in the specialty on the part of those
practising in it, as witnessed by :

(b) The institution of diplomas in psychiatry by the Univer¬
sities of Durham, Edinburgh, Manchester, Leeds, and Cam¬
bridge (enumerated in the order in which they adopted this
step). Besides which mention may be made of the fact that
in Condon and at the four Scottish Universities psychiatry is

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now a branch in which the degree of Doctor in Medicine may
be obtained. The institution of these diplomas is a recognition
of a movement of probably far-reaching importance, and it is
not an exaggeration to say that it marks an epoch in the
progress of psychiatry. That they will become registrable by
the General Medical Council is a further step which I venture
to hope will not be long delayed. Some of you are conver¬
sant with the beneficial effects upon the sanitary service of the
country which followed upon the enactment of the compulsory
holding of diplomas in public health ; and many of us believe
that similar benefits would flow from a like policy in the case
of the diplomas in psychiatry: not, of course, that it is in the
mere possession of diplomas that their potency resides, but
rather in the knowledge and systematic study of which they
are the hall-mark. The existence of these diplomas has already
emphasised the pressing need for :

(c) The establishment of psychiatric clinics. The fact that
one, to which I shall have occasion again to refer, will shortly
be at work in the metropolis under the a;gis of the London
County Council is a matter for earnest congratulation ; and
not less satisfactory is the recent erection at Cambridge of
laboratories for the prosecution of experimental psychology.
May the time rapidly come when these institutions will no
longer stand out as oases, when there will be none of our
medical schools which will not be in possession of both of
them, and when none of our towns of any magnitude is lacking
the former. The evolution of these clinics is one of the directions
towards which it is of paramount importance to secure not only
the sympathy but also the active intervention of general hospitals.
Such clinics would enable the study of the various branches of
psychiatry and psychology to be co-ordinated into a well
articulated scheme, embracing ante- as well as post-graduate
study ; and would be the means of securing, as is much to be
desired—

(d) A more satisfactory position for psychiatry in the medical
curriculum. Few, if any, teachers in psychiatry can be satis¬
fied with the position that their subject occupies in the medical
curriculum. The compulsory attendance on four-fifths of twelve
systematic lectures in the school, and twelve clinical demonstra¬
tions at a recognised institution for the insane, is what is
usually demanded of the medical student. The subject enjoys the

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distinction—some will say an enviable one, and there is much
to be said for their contention—of being the only compulsory
one in which (as respects by far the majority of qualifying
examinations) the student is not examined. Far be it from
me to advocate yet another addition to the student’s trials by
examination ; but it does seem to me anomalous that, of all
courses which the student is called on to attend, he is exempt
from any proof of competent knowledge in the one with which
the liberty of the subject is so intimately involved. Either the
certificates of attendance on the course (which is now compul¬
sory) should include satisfactory evidence of knowledge attained,
and work done, as well as mere attendances, or the final exa¬
mination in medicine, both written and clinical, should always
include a test as to the candidate’s knowledge of mental
diseases.

Adverting for a moment to the nature of this course—of
all subjects, the teaching of mental diseases is one which lends
itself rather to clinical methods than to systematic lectures ;
and freedom should be given to the teacher to proportion the
time between the methods according to circumstances. But
that privilege would go only a small way towards adequate
reform ; for as matters now and would still stand, the clinical
demonstrations necessarily all take place in institutions removed
from the medical school—commonly at a considerable distance,
though sometimes, it is true, comparatively near at hand. In
either event the student sees only certified cases of insanity,
and for the most part cases in which the stage of the malady
is considerably advanced. He learns something of the classi¬
fication of mental diseases, of the diagnosis of the forms as
they are presented to him in the asylum, and of their treatment,
and is instructed in the mode of filling in certificates of mental
unsoundness. This is all to the good, and I should strongly
deprecate the abandonment of asylum clinical demonstrations.
But what he almost wholly misses is an opportunity of seeing
those borderland and incipient cases, with the difficult technique
of whose examination he should have, if not a familiarity, at
least an acquaintance—that is, if he is to be competent to
render that spiritual aid, which, without encroaching on the
province of the priest, is more and more expected of medical
men ; for they it is, as said the Dean of St. Paul’s at the
last International Medical Congress, who now hear the con-

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fessions of anxious and conscience-striken patients. If it is
pardonable to glance at the commercial aspect of the question,

I have no hesitation in saying that on ability or inability to deal
with these cases will often depend the retention of a family in
the doctor’s general practice. Moreover, under existing arrange¬
ments, the student’s access to cases of mental disorder is usually
limited to a weekly visit, whereas it cannot be denied that of
all branches of clinical medicine the student of mental disease
should have, under proper supervision, free and daily access to
a mental ward and mental out-patient department.

For the realisation of these aspirations, I would again repeat**
that we must enlist the interest and energetic co-operation of
general hospitals, and in this direction I need hardly say that, to
my mind, the establishment at Middlesex Hospital of a special
department for nervous diseases was a very bright omen, even
limited as it at present is to out-patients, though the addition
of beds to it would, I am sure, materially add to its sphere of
usefulness.

(iii) Advice to entrants into asylum service .—Before quitting
the subject of the present unpopularity of asylum service I
should like to express, firstly, my conviction that, with the
recognition that has already taken place of some of the exist¬
ing drawbacks, the neck of the difficulty has been broken ; and
secondly, and speaking with a full sense of responsibility, my
hope that, despite any warnings he may have heard, no student
of this school who is willing to work hard and apply himself
seriously to the study of psychiatry as a branch in which to
specialize, will be deterred from following his bent. If I may
be permitted to offer a word of counsel, I would, however,
advise him to be cautious in his method of procedure, and
especially not to let considerations of £. s. d .—important though
they are—be the only nexus between himself and his choice
of place. After serving the usual term as house physician he
would be well advised to endeavour to attach himself to an
asylum affiliated to a medical school, whence, after an adequate
period of study and training, and after making sure he has
attended all the courses obligatory for one of the diplomas in
psychiatry, he can migrate to other institutions which, though
perhaps less favourably situated, offer advantages in salary
and promotion. No such aspirant for reputation in psychiatry
need, I am convinced, fear being side-tracked, and even if he

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I I

does not ultimately reach the position of superintendent—and
not every military officer becomes a general nor every naval
officer an admiral, or even a captain—he will be able to
present claims to an honourable and assured position which
cannot be disregarded.

(2) Psychiatry's claims overlooked by philanthropists .—Though
the pecuniary recompense paid to the actual toilers after
knowledge is too often slender, and in the nature of a pittance,
the progress of science, nevertheless, owes much to the liberality
of wealthy benefactors. To criticise the direction of their
benevolence would be a sorry and ungrateful act. Rather, did
time permit, would I enumerate all the endowments that have
been made in recent years to the various departments of medical
research. Such a catalogue, while redounding to the credit of
the donors, would serve my purpose by emphasising a patent
hiatus that most assuredly deserved to be filled in. For at any
rate during the twenty years in which I have been connected
with the specialty, with one exception, conspicuous 3s well by
its solitariness as by its munificence and far-sighted policy—I
refer to the Maudsley Hospital in course of erection—I cannot
call to mind any donations or legacies which have had for
their object the endowment of psychiatric research in this
country.

This is the second count in which I suggest psychiatry is
indeed and undeservedly the Cinderella of medicine. By no
manner of means can this cold shoulder which she receives be
explained by any lack of problems of interest; nor would it be
difficult to supplement a list of them with chapter and verse
of the immediate benefits that might be expected to flow from
their solution. It is to be doubted, however, if such a recital,
even though entrusted to a master in oratory, would be as
moving as knowledge gathered by personal observation—who
sees with the eye, believes with the heart—and there is no
little sagacity in the dictum that “ you cannot convert a man
unless you persuade him he is obeying the dictates of his own
heart.”

For that and other reasons it is a misfortune that so slender
a proportion of ratepayers, particularly of their intelligenzia ,
ever visit and make themselves personally acquainted with the
ninety-seven asylums which their money provides, and wherein
are maintained some 105,000 patients. Many of these insti-

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tutions are situated in country districts away from the throb
of active life, and except for the visits they receive from
official visitors, and from the friends of a proportion (often too
small) of the patients, they are left severely alone—verily, out
of sight, out of mind. And what would the intelligent ratepayer
learn ? Speaking generally, he would be amply satisfied with
all he saw, and that his money was being economically and
humanely spent; he would, moreover, be gratified to learn
that rather more than 30 per cent, of direct admissions to
these institutions are ultimately discharged as recovered. Here
and there he would be impressed by centres of serious effort
to unravel, with an energy deserving of the highest praise, the
perplexities which surround the cause and treatment of mental
affections. His interest aroused, as it inevitably would be,
particularly if it were backed by some knowledge of the
intensive methods of research, and their cost in other branches
of medical science, he would begin to inquire into what relation
the sums spent on psychiatric research bear to the cost of the
patient’s maintenance. He would probably be a little staggered
to learn that the latter (not even including the cost of repairs
to fabric and other capital charges) is well over two and three-
quarter million pounds a year ; but with what derision and
almost incredulity would he hear that, at a liberal estimate, it
would be hard to show that even so insignificant a fraction as
o'2 per cent, of this sum is spent in organised scientific research?

It is, however, a fact of much significance and one very
pleasing to chronicle, that quite lately the Government has set
apart, to be distributed by the Board of Control, the sum of
^1500 to be spent in each year in the encouragement of the
investigation of mental defect in the broadest sense of that
expression—thereby setting the imprimatur of the State upon
the claims of psychiatry. This recognition, and the advent of the
Maudsley Hospital, are bright streaks which, it is to be hoped,
herald the dawn of a brighter day for Medicine’s Cinderella.

(b) Cause of Present Position of Psychiatry.

The essential cause of the present position of psychiatry has
its roots in the past, and is undoubtedly the divorce that has
been decreed between it and other departments of medicine.
This is due to the prevailing custom, not only of treating the
majority of cases of mental disorder in institutions devoted

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solely to that end, but also of refusing to admit such cases to
general hospitals. This custom is not new, for we have
records of the existence, as far back as the year 1400, for
example, of a small establishment at Charing Cross, and another
at Harking, for at least the segregating, if not the treatment, of
a few insane persons ; and it probably owes its origin to the
failure to realise that many morbid mental symptoms are due
to the same pathological conditions as are the symptoms of
other systemic diseases. That “ a precedent embalms a principle ”
has surely been exemplified here, and nowhere, I should
imagine, with more disastrous results ; more particularly has
the custom retarded progress in the case of those areas which
have the good fortune to possess within them a university—
with which intimate co-ordination of research workers, in lieu
of the mischievous and wasteful system of segregation, could
have been sought.

It cannot, I admit, be gainsaid that, at least superficially,
there are serious differences between cases of mental disorder
and cases ordinarily regarded as eligible for admission to the
wards of a general hospital. Though each of these differences
presents difficulties of its own, I cannot agree either that any
one of them ought to be allowed to be a ban on the patient’s
entrance into a general hospital, or even that all of them in
conjunction constitute any insuperable obstacle. On the
contrary, I urge that the time has come when they should
cease to be permitted to encompass a gulf, almost indeed as
“ profound as that Serbonian bog,” which has so long separated
the treatment of mental from other forms of disorder.

Psychiatry?

General hospitals can benefit psychiatry by bridging over
the gulf to which 1 have just alluded ; and this, I submit,
could be effected by the establishment in general hospitals of
mental wards, with corresponding out-patient departments. In
the case of hospitals in association with medical schools they
would naturally assume the form of full psychiatric clinics.

Specialism in General Hospitals.

Specialism in general hospitals has most assuredly come to
stay, and though some deprecate its triumph, they may at least

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14 the position of psychiatry, [Jan.,

take comfort from the fact that in its birth it was the twin of
the inevitable complexity born of the progress made by
medical science. The tendency to build special and
independent hospitals for this and that disorder seems, and I
think happily, to be on the wane. This has been effected by
the response made by general hospitals to the demands of
specialism ; and now many a large hospital strives to have
under its own roof departments for all the specialties that have
arisen—wards for diseases of the eye, of the nose and throat,
of the ear, of the skin, for nervous diseases, for genito-urinary
diseases, for cancer, children’s wards, maternity wards, and a
dental department. But the gamut is incomplete, for if there
is one department that, willy-nilly, has been dubbed a specialty,
it is psychiatry. Yet in our own country, so far as I am
aware, not a single general hospital can boast a psychiatric
clinic in the full sense of the term.

The debt that the public owes to general hospitals and to
their medical staffs, who gratuitously and so lavishly give their
time, would indeed be hard to compute. It sits lightly on the
shoulders of most of those who use those institutions, because
they are ignorant of the work that goes on within their walls ;
they regard the cure of their malady as an empirical procedure.
It is only the more enlightened that have any glimmering of
the fact that each case is a new problem ; that its history,
course, and result are laboriously recorded, and are subsequently
not pigeon-holed as dust collectors, but classified to form a
living library for reference in future cases.

Consciousness of this debt, and desire not to be presump¬
tuous, make one hesitate in any way to criticise ; but, if I may
be forgiven using a somewhat hackneyed quotation, I will take
leave to say to general hospitals, and to throw into my question
a spice of reproach, “ Canst thou not minister to a mind
diseased ? ” I am convinced they can if they will.

The Psychiatric Clinic.

Mental wards in general hospitals are not an entirely modern
conception. There may have been other examples ; but it is
certain that in the year 1724, when Guy’s Hospital was
established, its founder stipulated that insane persons discharged
from certain other general hospitals were to be received ; and

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in 1797 a special “ House” in connection with the hospital
was built which continued to receive insane patients down to
the year 1859. That it was not a success, and that, down to
its abolition, the then Commissioners in Lunacy pressed for its
removal into the country, are facts which have sometimes been
put forward as evidence against the soundness of the
principle. But the further fact should be noted that it was
expressly stated that the twenty cases, which this mental ward
was to accommodate, were to be all certified as incurable ; and
it is indisputable, from the ward’s annual returns, that it was
not uncommon for a year to pass without any admissions, that
discharges were few, and that apparently none were recorded
as having recovered—surely the negation and antithesis of our
conception of a psychiatric clinic.

The ideal psychiatric clinic has probably yet to be developed,
and each new one should mark in its design progress in
method of treatment. As regards this country it has as its
prototype the admirable admission hospital which now exists
as a detached unit in several of the county asylums. While
brains are more important than bricks, no little cunning is
nevertheless requisite in the actual design of the building :
for, besides adequate out-patient rooms, it internally has to
provide accommodation for every type of mental case, so
arranged that no patient need be disturbed, alarmed, or suffer
any shock by the behaviour of a fellow patient ; and withal,
as much of the treatment in bed as possible should be capable
of being in the open air. There must, moreover, be means of
classifying the patients according to the stages they attain
towards convalescence. Opportunity should be provided on a
liberal scale of employing every known special form of treat¬
ment which experience teaches promotes mental recovery.
Properly equipped clinical rooms for examination of patients
on admission and afterwards are essential. Rooms adaptable
for work in practical psychology should be included, and a
certain amount of laboratory space would also be needful ; but
as to the latter, the situation of the clinic, within, or in close
proximity to, the curtilage of a general hospital, would enable
advantage to be taken of existing laboratories.

That such an institute could prove a failure is as inconceiv¬
able as inestimable would be its benefits.

Out-patient departments .—As ancillary adjuncts to the wards,

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mental out-patient departments would, of course, be a necessity,
and of their power to stave off many a threatened mental
breakdown I have not the shadow of a doubt. In the general
hospitals attached to a few medical schools (among which is
Middlesex Hospital) and in at least one public asylum they
already exist; but I can see no reason why they should not
be established in connection with every general hospital in the
country, nor why the expert knowledge of the medical officers
of institutions for the insane should not be freely available
and utilized—that they would be readily given there need, I
am sure, be no misgiving. Such out-patient departments, if
they are to fulfil all the functions I have in view, should be
attached to the general hospitals, and not to the asylums.

Mitigating the stigma of insanity. —Owing to much misunder¬
standing, both as to the liability to relapse, and on the question
of the influence of heredity, a most unfortunate stigma attaches
to a person known to have had a mental breakdown, especially
if the case has been placed under legal certificates. Whilst
wholly undeserved in a large proportion of cases, how real it is
in the view of the public, and how powerfully it operates as a
deterrent to prompt and efficacious treatment, only those of us
who see these cases fully appreciate. No amount of preaching
will stifle this sentiment; but the institution in general
hospitals of the psychiatric unit, access to which could be
obtained through the ordinary portals of the hospital, would be
the most powerful factor possible in nullifying its evil influence.

Teaching facilities. —Upon the advantage that would accrue
to the students, and to post-graduate study and research, I have
already dwelt. Our students, by daily observation, would be
enabled to familiarise themselves with cases not crystallised,
but in plastic and incipient stages—the very forms that they
will meet in general practice.

Opportunity would also be given to the general nursing staff
in turn of becoming acquainted with mental nursing—to the
advantage of both branches of nursing.

Legal restrictions have sometimes been advanced as reasons
against the possibility of use being made of general hospitals
for that purpose. Speaking quite unofficially (as I am through¬
out this address), I would merely say that I believe that the
legal difficulties have been exaggerated, and I do not think
they would operate to prevent the establishment of psychiatric

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clinics. It is true that to utilize the latter to their full extent
some amendments in the present law would be needed, and
there is good reason to hope that .ere very long these will be
obtained, and that among other facilities they may render
possible co-operation between asylum local authorities and the
governing bodies of general hospitals.

Concluding Remarks.

My task is done. If this address has consisted only of
commonplaces, each useless perhaps by itself, my object has
been to bring them to a focus, to place somewhat more in the
limelight the claims of psychiatry, and to put forward a plea
for a wider sympathy with its needs. If peradventure one be
found here whose attention has been engaged by any of my
remarks, I beg him not to be satisfied with taking for granted
what I have said, but to look into the question for himself; I
have confidence that his interest, once aroused, will not flag,
but will bear fruit. As to the part in the problem I hope some
day to see general hospitals play, if not presumptuous, I would
venture earnestly to ask the authorities of this hospital to con¬
sider the feasibility of adding to their units a psychiatric clinic.
Has it not been the steadfast determination of the Middlesex
Hospital to provide the fullest opportunities for teaching, study,
and research in every branch of medical science, not only as
respects the preliminary and intermediate subjects, but also on
its clinical side ? If I have dared to suggest that a gap exists
in the latter, it is one that, as far as I am aware, is common
to all other general hospitals in this country, and if the
Middlesex Hospital resolved to lead the way in filling it in, or
bridging it over, its action would surely be no departure from
its considered policy, but rather the fulfilment of its highest and
best traditions.

(') I.e., October, 1914.

Remarks on the Interpretation of Dreams, according to
Sigmund Freud and others. By F. StJohn Bullen.

For a long time attempts have been made to discover
definite relations between external and internal stimuli occurring
during sleep and coincident dreams, as also between dreams
I.XI 2

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and the more or less momentous happenings preceding them
during waking hours. Such attempts as have been made to
prove obvious connections have mostly failed, and for reasons
which for the first time are set forth by Freud. At the same
time, he has demonstrated the subtile evasions and tortuous
routes which pertain to the operations of stimuli on the way to
dream-consciousness, whether they be sensory or purely phy¬
sical, as well as the indefinite period of time over which
reminiscences, which are concerned in the evolution of the
dream, may extend.

It is impossible to summarise the extensive researches of
Freud except by dealing seriatim with the various segments
into which his work is divided, and that is the course here
adopted. At the same time I have not merely limited myself
to the discussion of Freud’s theories, but have surveyed other
literature, and treated the whole subject in a critical attitude.

Firstly, as to the source of those stimuli which modify dreams
during slumber.

Of the influence of objective (/.<?., presentative) stimuli there
is no doubt, but as to the immediate correspondence of the
dream with them there is uncertainty, for the reaction of the
mind is rarely determined by correct associations. Illusions
are often brought about by faulty linkings, or by the awakening
of several memory-pictures, the selected survival of any of which
is not predicable.

Of the subjective sensory stimuli, the retinal are said to pro¬
vide the main source of dream-pictures, with which, indeed,
they may be identical.

Of one thing we may be sure, that the actual material of
the dream is central : distinct “ presentative dream ” is out
of the question. Presentations can seldom do more than arouse
consciousness. If, however, they do enter it, apperception and
will being quiescent during sleep, they are accepted with greater
or less absence of criticism.

In the waking state, the relations between mind and body
are ill-defined, but, during sleep, the conscious interdependence
is more marked, and stimuli, which under the former condition
lie latent, become recognisable in the latter, when the trans¬
mission of external impressions is no longer accomplished. Thus
occur the harassing dreams often associated with heart and lung
disease, dyspepsia, the erotic dreams of sexual excitement, etc.

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These organically determined sensations arrange themselves
in two groups, general and specific, and to the latter belong
muscular, pneumatic, gastric, and sexual impressions.

In regard to all the stimuli whose sources have been men¬
tioned, the pertinent fact to be remembered is that they are
not directly placed before the mind’s consideration, but are
allied to “ dream-presentations ” according to certain rules, and
it is these presentations, and not the sources on which they
depend, that are dealt with in dream-consciousness. In other
words, these organic stimuli are not delivered in literal form,
but changed within the brain, in apparently unrelated symbols,
for the purpose of objective demonstration. Thus, disturbance
of the heart’s action produces a feeling of effort or obstructed
movement.

At the root of this process, as we shall see, is mental dis¬
sociation and reconstruction on the basis of imperfect association¬
working.

Much of the material forming the dream will have originated
amongst the experiences of the few preceding days, although
these can be modified in their presentation by external and
internal stimuli, and by psychic episodes. At any rate, events
occurring during these days antecedent to the dream not only
have a preferential influence, but, at least in some details, are
invariably represented. Thus the happenings of these few
days need scrutiny in the process of elucidation of the dream¬
meaning. But the source of the dream, although preferably
sought for amongst recent events, may extend so far back as
the reminiscences of childhood. In this case, one may surmise
that such early images which have been obscured by the mass
of later acquisition, and left beyond the range of the average
circulatory and nervous tidal waves, can only have been allowed
to revive by the removal of this incubus, owing to the influence
of some toxic or structural lesion or change. When the
reminiscences do appear, it seems that the emotional state
which originally accompanied them may have undergone per¬
version.

The source of the dream, however, whether recent or not, is
admittedly difficult to trace, for, in the main, the dream-
subjects are trivial, and to be only regarded as a current in
reverse of the impressions which have been received during
the previous few days ; a stream, too, largely deprived of

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matters which have really conscious consideration. So that it
might well be accepted that it is only impressions of a trivial
kind that obtain prominence in consciousness, although not the
fulness pertaining to more definite thought.

According to Freud, indeed, as will be seen later, these
trivialities actually do survive, because the want of importance
enables them to escape repression ; their purpose being, never¬
theless, of moment, in so much as they are said to serve as
carriers in disguised form of those unconscious ideas which have
been rebuffed in endeavouring to penetrate consciousness.

Apart from this, a prominent cause for the insignificant
character of most dreams must be sought for in the feebleness
of the association work; the penetration of the necessary
tracts requires effort beyond that available in the dream-state.
If, too, normal paths of association are closed, any direct con¬
junction of ideas is prevented, and thoughts which should be
mutually interdependent occur separately or are presented in
forced and unnatural contiguity; they are thus fragmentary and
fleeting because ill-organised.

This in itself argues a limitation of the psychic sphere in
dreaming, but there are, however, two theories concerning the
amount of the involvement.

First, that the full activity of the mind exists, although
placed under unusual conditions : here is found an analogue to
paranoia. Secondly, that there is a diminished psychic
activity ; the invasion of mind is patchy, or there are, again,
isolated areas of inaction such as may be supposed to exist in
dementia or amentia. In the second group, coherence in
thinking or imagery increases towards awakening, as the
dissociated groups of nerve-cells become restored to synergic
activity. Against the completeness of this theory Freud pre¬
sents the evidence of the meaningful and intelligible forms of
dreams which sometimes occur, and in which all signs of a
lowered or subdivided activity are wanting.

Dreams are readily forgotten, and this depends on the con¬
ditions just mentioned, also on the want of attempts made to
recall them, and again on the fact that the actions in dreams
are largely portrayed by means of visual symbols. Hence the
links of association between sound and vision, ideo-motor and
so forth, are only narrowly and loosely formed, or are based on
casual similarities.

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The really momentous contents of the dream, as already
inferred, are in the main prohibited from reaching the conscious
level by the repression of what is termed the “ endopsychic
censor ” ; hence for the manifestation of these contents the
relative resistance of the censor and the relative energy of the
unconscious forces are the important factors.

In children the dream appears often and evidently as the
fulfilment of a wish, and in adults its appearance is equally
significant to Freud. Although it is recognisable occasionally
in the adult in such direct forms as the imagined gratification
of a desire to quench thirst, to micturate, to obtain sexual con¬
gress, to accomplish aerial flight, to have restored the cata¬
menia in the case of an unwelcome pregnancy, yet the wish-
fulfilment is more often concealed or disguised because of some
repellant attitude exercised towards it by the censor.

Impressions, too evasive or indeterminate for analysis and
control, which exist in the subconscious life, on passing the
barrier between this and consciousness are brought into the
sphere of active feeling, and in accordance with normal proce¬
dures are analysed, welcomed, or rebuffed, distorted, disguised,
or modified into some acceptable form. The expression of a
wish may thus appear under disagreeable circumstances on the
surface quite at variance with its nature. But the manifest
dream-image in such an instance is to be regarded as a distor¬
tion of the real thought, and not as representing directly the
wish. The painful character only indicates the attitude or
emotional atmosphere aroused at the admission of the dream to
consciousness.

Most of Freud’s illustrative cases arc too long for quotation,
but one instance admits of compression, and seems to
exemplify his theory that a wish-fulfilment may appear under
a sombre disguise. It is as follows :

A woman who, much to her grief, sustained the loss of a
favourite nephew, had a dream in which she saw another
nephew dead and lying in his coffin, with certain ceremonial
adjuncts similar to those of the real death. Her emotion is
one of profound distress. This vision, at first sight, it appears
unfeasible to regard as a wish-fulfilment. But Freud gives the
explanation that the woman had a secret affection for a certain
professor (from whom, by the interference of the dead child’s
mother, she had been alienated) and had been in the habit of

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indulging her penchant by taking every opportunity of being
in his presence. After the death of the child the professor was
in her company, standing at the side of the coffin. The feeling
that the death of the second child would allow a repetition of
a longed-for meeting instigated this dream. Thus the selection
of a sorrowful episode was an attempt to disguise the real wish¬
seeking expression.

In the majority of cases dreams having origin in wishes do
assume a painful character as a result of repression. The
obverse, however, occurs in so far that states of thought and
feeling may be engendered during sleep of a complexion quite
contrary to that of waking hours. Hence the dream may
prove a relaxation, and a suggestion of escape from day-
depression.

In either case, Freud would have it that the result is a modi¬
fication produced by the antagonistic attitude of the psychic
forces represented in the formulated wish and the censorial
repression.

The constitution of the dream comprises two states or
functions. First, the provision of the latent dream-content or
dream-thoughts, and secondly, the transformation of these into
the manifest dream-content, which is another form of expres¬
sion, so to speak, a form of picture writing, needing to be read
in the same way as a rebus and not as a direct sign. At the
best, however, it may be said, an indifferent process of sym¬
bolism.

The relationship of these two states is of the highest impor¬
tance. The latent content or dream-thoughts which lie at the
back of the dream imagery are the correct material of the
dream, its essential meaning, drawn from the ideas which
have not come into consciousness. Constituting the pith of
the dream as these do, they have, however, of necessity, no
direct or invariable relation to the dream imagery, into which
they are ultimately translated by an activity special to, and
characteristic of, dream life : a process qualitatively different
to the methods employed in waking thought.

This process, which Freud terms the dream-work, involves
many complicated readjustments, which arise out of the re¬
pressive attitude of the censor (or endo-psychic factor).

Amongst these is displacement, or the substitution of indifferent
for important material, a method by which an experience of

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2 3

moment may be regularly represented by a trivial impression,
and one which may be regarded as intentionally devised to
secure for the serious matter the evasion of the censor, and the
atmosphere of pain. Freud maintains that there is a funda¬
mental tendency in the mind to suppress every experience that
is associated with painful emotion.

Elements apparently of essential nature in the dream thus
do not necessarily become at once recognised as being of
importance. Indeed, it is rather frequency of occurrence (or,
on the other hand, assemblage of similarities) that determine
appearance in the dream, or what is termed “ manifold deter¬
mination.” This process of dream displacement, therefore,
involves the reduction in value of elements of high psychic
intensity, and the appreciation through manifold determination
of elements of seemingly low value. A revaluation, so to
speak, of psychic material is brought about. Freud remarks
that transvaluation is shared by different dreams in extremely
varying degrees. There are dreams which take place without
any displacement; the more obscure and intricate the dream,
the greater is the part to be ascribed to the impetus of dis¬
placement in its formation.

Displacement also includes (i) the substitution of one idea
for another, the second being in some way connected with the
first, and (2) the concrete expression of an abstract word by
which it can be visually depicted and more easily represented.
Words used conventionally in a faded, abstract way may have
their old vivid meaning restored to them, eg., “ one has got
oneself in a hole ” or “ one will have to take flight.”

Visual images thus aroused by transformation are naturally
influenced by presentability in the scene, that is, suitability for
pictorial representation ; the seriality of these scenes exercises
a more potent control than the progress of coherent thought.

Yet another process is involved with the preceding ones of
displacement and determination, viz., condensation. This com¬
pression is great, as compared with the range and profusion
of the dream thoughts. It may be accomplished by an ellipsis or
jump from point to point, but in the main there does not occur
any mere uniform condensation, but a process of selection or
exclusion following on an elaboration of the dream thoughts,
according to the relative strength or weakness of certain
elements. Thus, elements resembling each other mutually

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reinforce, as features common to a family are emphasised in a
Galton composite photograph. A process of collecting and
compounding is most important in dreaming : similarity, agree¬
ment, community, are expressed as a unity either by identifica¬
tion of several things as one, or as a composite unit.

As already has been indicated, the essential complex of the
dream thought need not, therefore, be represented at all
in the dream ; the manifest content, or imagery, may be
grouped round other and less important material. Associa¬
tions also may be modified for the purpose of furthering some
serial procession of images. Thus varied values are treated
on an equality ; composite or collective mergings of persons or
things are formed ; words are treated as actualities rather than
as symbols, and undergo distortions,substitutions,and ambiguous
interpretations. All these vagaries in penetrating the manifest
dream content are transformed into scenic parade. Small
wonder that, as Freud admits, an overwhelming number of our
dreams arc incoherent, complicated, and meaningless !

The last process is that of regression of thought, whose
hinder limit during waking hours is the plane of “ memory-
pictures,” but which, during dreaming, still further dives down
to perception level, and evokes the images from which the
memories originated. This constitutes the so-called hallucinatory
dream. A striking analogy is supplied in this regression to
the “ raw material of thought ” to hallucinatory delirium of the
insane ; in both a loss of relativity in thought is involved.

The regressive progress in the child is a fundamental one,
by which response to, and gratification of, some physical or
psychic need is made. The revival of the memory-picture
of that perception, which at the first was co-related to the
satisfaction of the need, proving inadequate, fresh mental pro¬
cesses are started which underlie the wish.

This explains the more ready fulfilment of desire in child¬
hood’s dreams. The child only assimilates gradually his
peripheral sensations into himself, and consequently tends to
objectivate his feelings, and regard them as outside himself.
Like all primitive beings, he tends to confer his vitality on in¬
animate objects. It is characteristic of his mental processes,
according to Havelock Ellis, that daring fusions and abnormal
logical tendencies should occur ; that prone to reverie he should
be liable to confuse dreams and reality. In the dreams of his

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elders the same things happen, and thus, says Freud, “ the
dream of the adult is but the abandoned psychic life of the
child.” The dramatisation in the dream of the child is, how¬
ever, more vivid in kind, whilst it is less impeded by memories
and experiences.

In the interpretation of the dream, all these processes of
displacement and distortion, condensation, compromise, scenic
illustration of abstract thought, together with the realisation of
the wish-influence, and the important part played by child
reminiscences, and immature as well as mature sexual instincts,
have to be borne in mind.

There arc numerous dreams analysed by Freud which serve
as guides in penetrating the mazes of the dream-life, and these
illustrate the existence of a plasticity of psychic material
which at one time may need a literal, at another a symbolical
interpretation to be given to the dream content. It seems
likely, too, that the patient may create his own type of
symbolism.

Freud, as is well known, assigns a sexual basis to most of
the phenomena observed, and that he docs so frequently is not
astonishing, seeing that he asserts that dreamers may use any¬
thing, however ambiguous, as a sex-symbol ; moreover, that
there is no series of associations which cannot be adapted to
the representation of sexual facts. A most extensive list of
symbols connoting the sexual organs and functions is afforded,
including umbrellas, nail-files, cravats, aeroplanes, tables and
boxes, which would have overwhelmed even Rabelais.

There are several dream experiences, well known to most,
which Freud considers of typically sexual origin. Amongst
these we find the sense of nakedness accompanied by shame
and inhibited movement, and it is notable that in these visions
the imaginary spectators are both unknown and indifferent,
being probably dream-substitutions in a negative attitude of
some person for whom sexual exhibition was intended. All
fear, anxiety, and impeded movement (negation of volition or
conflict of will) are considered as of sexual origin : that is, as a
“ libido ” which has been thwarted, turned away from its object,
and transformed into fear. This “ libido ” is not to be trans¬
lated invariably, however, as a crude sexual desire.

Dreams of dental irritation and extraction, although more
uncommon, are believed by Freud to denote cravings for self-

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abuse. This interpretation illustrates the latitude which Freud
allows himself in the process of analysis. To be brief, dental
irritation is a transference from under to upper regions. In
the symbolism of unconscious thought, genitalia are replaced by
face, various features about the two regions are made inter¬
changeable by suggestion. Teeth alone have no counterpart
in the nether regions, hence from this disagreement are pro¬
jected under force of sexual repression. Again, the sound-
resemblance of the word “vogeln” to a coarse expression, is
supposed to confer a sexual significance on the appearance of
birds or birds’ heads in a dream ; even on the sensation of
flying , which is familiar to us all. Another and more plausible
explanation of this curious feeling, however, is that of the
reproduction of the infantile impressions of being dandled, or
swung to and fro. The sense of assurance that the dreamer
has been in some locality before is stated to have reference
always to his previous occupancy of his mother’s womb.

This is, indeed, a disinterment and detachment of the faintly
realised and assimilated sensations of embryonic life, and
Freud’s theory seems to us an unwarrantable attempt to bring
a mere condition of paramnesia under the group of sexual
reminiscences. The conditions favourable to pseudo-reminis¬
cence are in fact present, viz., lowered mental tone and lessened
attention, defective synthesis, faulty adaptation to the pre¬
sentations of the moment. Just the state, in short, where
reminiscences are equalised in value to sensations on the one
hand, or to images on the other. There is no reason to
question the identity of this state in waking and dreaming.

And the sensation of flying has been, we think, much more
correctly ascribed to respiratory stimulation, conjoined to
diminished consciousness of tactile pressure due to anaesthesia
of skin. The feeling of floating is known to us during ether
administration. Ellis remarks on its occurrence in the dying,
and as due here to the concentration of life in the brain and
central organs, and to numbness of the periphery. We are
here reminded of the anaesthetic states associated by Stoddart
with visceral liyperaesthesias.

In these and many other instances there is no doubt that
Freud exercises his agility in interpretation to a perilous degree,
but his genuine profundity of analytical power must not be
invalidated by such examples of strong bias in sexual matters.

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Dreams of beloved and defunct relatives, said not to be
uncommon, are to be interpreted in two ways, according to
whether the dreamer is unconcerned, in which case the dream
does but supply an emotional atmosphere to a latent and
unrealised dream-thought, or the dreamer is affected. In this
latter case it implies that at some time in the dreamer’s life the
death of the person dreamt about has been wished.

Here Freud lays stress on the forgotten once-time egotism
of the child, and its selfish or hostile impulses ; also on its
sexual differentiation. This period of its life he regards as an
unmoral one, often uncovered in later years by hysteria, or
revealed in its failure to receive correction with the oncoming
of puberty, a condition rather to be viewed as an arrest of
development than as a degeneracy.

We see, then, how essentially Freud’s views of the dream
differ from those usually entertained. Instead of returning
consciousness being indicated by an irregular shifting imagery,
without purpose or logical connection, and mainly influenced
by the tone of ccenaesthesis, the dream being in brief but the
preface to awakening, we have Freud’s theory of the dream as
a protector of sleep by its processes of avoidance of pain and
pursuit of rest, and again as having a definite origin in desire,
reinforced by an organic impetus derived from unconscious
memories. Thus with him the dream is the outcome of a
desire checked in its full expression, and diverted to other
forms of display ; it is always purposive and significant. The
first process in the dream is the conglomeration of isolated
presentations, all of which, however, have a certain basis,
forming a kind of Galtonian photograph. Then arrives the
process of displacement of subjects and transference of values,
by which superficialities of the dream serve to cloak, whilst
symbolising, the real thoughts and feelings of the dream.
Then there is the dramatisation of the whole collection of
elements into a succinct episode.

As is well known, Freud ascribes all psycho-neurotic sym¬
ptoms to the conflict between the wish-fulfilments of the
unconscious and the censor. The activity of the latter lessens
during the night, when dreams are allowed to pass it under the
rule of compromise-formation. On the contrary, the gaps in
serial thought during deliria are said to be due to its over¬
action and ruthless repression, whilst its pathological enfeeble-

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meat, together with forceful excitation of the unconscious,
allows ideas to be translated into uncontrolled action.

It may well be that the mechanism adopted by Freud to
explain the wish-fulfilment and other complexes during dreams
is over-elaborated, and bears too much the impress of an artificial
system created to tally with the phenomena rather than a
genuine solution. We have to beware, in these intricacies of
explanation (in the words of Lugaro), “of the excessive pre¬
judice of certain psychologists, who would find, at all costs, a
link of causal connection between mental phenomena which
succeed each other in an incoherent and disorderly manner.”

Freud, then, assigns the various evasions and distortions of
the wish-fulfilment to the attitude of censorial repressions.
Whilst other conditions may influence the vagaries and incon¬
gruities of the dream, he confers on the censor the burdensome
role of bringing about a most complex and intricate play of
substitution processes which hitherto had been regarded as
mere inconsequent results of untrammelled ideation, due to
removal of control during sleep.

Now, the constitution of this so-called censor may be viewed
in two aspects. In one it represents a fundamental mechanism
for causing the avoidance of pain, by diversion or transforma¬
tion of the impression. In another and later stage it produces
a restraint of the dream-effects, i.e. } it deliberately inhibits,
sets aside, or walls up those tendencies which it is proper to
check.

In the first case it bears an evident relation to emotion ; in
the second to morality and convention ; so that, broadly viewed,
it is developed on a series of attitudes antagonistic to instinc¬
tive tendencies. (We have, of course, to realise that Freud’s
censorial repression is not limited by any rigorous conventional
attitudes in the ordinary acceptance of the term, but merely
expresses a special antagonism to certain ideas and desires
presented to it ; these need not be noxious in nature.)

The result of the negative position of the censor towards the
emotions that try to pass it would be to create a state of
tension and restriction, but that such state should exist under
the conditions of dissociation prevailing during slumber is un¬
likely : the suggestion of emotional stress or of repression at
this time is disfavoured. The whole question of the promi¬
nence of emotional states during dreams is a vexed one

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With Freud, the action of the censor in dispersing emotional
agitations by transformation of the dream-material, where this
involves it, is the main feature of the dream-work, for, by this
means, the wish-fulfilment is got through in some, albeit in
disguised, form. Emotion, however, when it does appear, often
bears indifferent or erratic relation to the nature of the dream-
thought. This has been explained as the result of the stability
of the emotion, whilst the dream presentation has undergone
displacement; or, again, that the affect has been entirely
separated from its proper idea.

With Havelock Ellis, however, emotion is the fundamental
source of our dream-life, and the chief function of dreaming to
supply adequate theories to account for the amplified emotional
impulses which are borne in upon sleeping consciousness. He
also finds in emotion the basis of the symbolism which plays
so important a part in dreams, inasmuch as with a similar state
of feeling there occurs an association of spiritual and physical
states. Ellis believes emotion and morality inseparably con¬
nected, even in dreams, but one may demur that, however
active the part played by emotion in the dream, the influences
of morality and convention are seldom noticeable, nor in the
existent state of mental dissociation likely to be so. This
latter, and the levelling of mental processes to a common value,
result in more primitive conditions under which inhibition is
but imperfectly exercised. Hence the most extraordinary
situations arising often occasion neither surprise, shame, nor
grief in the dreamer.

Thus it does not seem likely that during sleep there is any
obvious censorial repression at work in its conventional aspect;
but the more primitive and emotional tendency to the sup¬
pression of mere pain may yet be to some extent in force.

If emotions play no great part in dreams, and censorial
action dictated by morality and convention is unlikely to be
momentous, there can be no weighty obstruction to any ideas
repressed during waking life escaping and rising into conscious¬
ness during sleep. There may thus be no need to ascribe to
the censor the whole responsibility of the extraordinary imagery
of the dream.

Freud, however, only concedes that during sleep a relatively
less active state of his censor exists, and he explains all the
vagaries of the dream-pictures and thoughts by the aforesaid

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elaborate machinery of divergencies, transformations, and so
forth, destined to avoid this repression. If, therefore, a wish
ever arrives at fulfilment in the dream, it must be in a dis¬
guised shape, a form which demands interpretation. Freud’s
contention is that in whatever aspect it appears, it succeeds in
arriving, and is to be recognised by certain methods.

One may pause to inquire whether (with the few exceptions
in which the supposed realisation of the desire is after all but
faintly accepted by the dreamer) the wish-fulfilment could ever
be attained in dreams, quite apart from any censorial action. In
the first place, the conditions during sleep are against the neces¬
sary tension of apperception and selection of ideas required to
carry this through; all the characters of dreaming rather suggest
the wide range of ideas, the narrowing of focal consciousness,
and the impartial presentation of all phases of waking life,
whether trivial or grave. VVe should conjecture, too, that the
emotion and motor determination involved in the attainment
of the wish would result in awakening when the climax was
reached. But it is conceivable and likely, seeing how near we
can approach to consciousness before actually recovering from
an anesthetic, that the dreamer may arrive at the stage nearly
preceding wish-realisation and yet remain asleep. Is there,
however, any other explanation for the apparent negativing,
falsifying, and evasive action attributed to the censor during
sleep? Are these processes due to another condition habitually
concerned in the mechanical routine of thought ?

VVe have to consider that during sleep, mental processes,
apart from the dissociated action of the various brain-organs,
take place on a lower plane, and tend to be presented in con¬
ditions short of full and perfect working. In other words, we
incline to the belief that many of the suggested prohibitions
of the censor, as instanced in the well-known “ contraries of
dreams,” are due to the imperfectly balanced action of con¬
trasted ideas. There is no need here to dilate upon the origin
or importance of these. The whole evolution of race and
individual must have depended largely on the experience
acquired from negative as of positive attitudes. Even in these
civilised ages, when the experiences handed down by our
forebears have conveyed a valuable stock-in-trade of negative
attitudes which can be taken for granted, the education of the
individual implies a constant alternate presentment of mutually

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exclusive states, by which an approximate balance in ideas is
preserved, and the too rapid, perhaps haphazard, course of one
line of thought is prevented. Anyone familiar with systems of
artificial mnemonics knows the use that is made of “opposite
ideas,” and will also have observed that of all varieties of
association-processes this is the readiest, simplest, and most
automatic. Indeed it may be said to be almost the rule that any
train of thought is followed by one contradictory in attitude.

Thus, an idea is only comprehended by placing it in
contrast with its opposite, i.e., it has only a relative value. It
is said that in primitive speech a word expressive of quality
merely conveyed the relation between qualities rather than the
qualities themselves.

Normally, the halting balance between contrasting ideas is
determined by an active attitude based on the more consider¬
able backing from desire, experience, and so forth, and the
ultimate decision involves an increasing avalanche of these
factors, with accompanying increase of tension. But the
predeterminant state will always be one of negation. It may
be that in the dream of wish-fulfilment this stage is not passed.
When the wish is on the verge of its fulfilment, the inevitable
contradictory phase arises and remains dominant, because the
further tension which would be engendered in attaining the
wish would cause awakening. Before this could happen the
lack of restriction in the association processes would probably
allow the impulses to wander and the crisis to pass.

In these opposing states, negative and positive, the expe¬
rience and temperament of the individual must weigh, each state
being reinforced according to the support given by memories
and associations. The disposition of the neurotic person is
marked by a defensive attitude, timidity, or hesitation, as
against a normal assertiveness, confidence, and determination,
and hence in dreams, as in waking, there will be a tendency to
negative polar attitudes.

Freud, himself, recognises the association of reverse atti¬
tudes of fear with desires, and Nacke has described contrast
dreams, in which the character and actions of the dreamer are
represented as opposed to those of his real self. Such dreams
do not exemplify concealed desires, but merely personal
peculiarities and potentialities.

Moreover, it is not necessary to assume that these contrasting

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32 THE INTERPRETATION OF DREAMS, [Jan.,

ideas are to be considered as negative phases, the exact opposite
of the presented image or thought. They arc liable to exhibit
the lot of the generally shifting and ill-controlled imagery
suggested by all the realisable inconsequences of unrestricted
association.

We must recall that in sleep, as in conditions where volition
is impaired and mental reduction prevails, a state of negation
or antagonism is favoured, or occurs involuntarily and without
necessary dependence on delusion. Attempts at serial pro¬
cesses in the dream are mostly defeated by these distortions
and incongruities arising out of the use of the very processes
necessary to carry on consecutive ideas ; it is the short phases
of trivial representations in dreams that seem clear and
realistic, because of their want of intricate connections. From
this cause, too, the recent trivial incidents are so common in
dreams ; they are by chance reproduced in active presentation
by a flushing wave of foreconsciousness, just as a detached
fragment of floating wreckage becomes a more prominent
sport of the sea than the coherent mass from which it has
been separated.

The influence of suggestion on the sleeping brain is also a
question for consideration. From the objective side, suggestion
can be but limited ; from intrinsic causes, it may be limited
only by the ability to furnish a steady relay of associated ideas
and experiences. But, from the vacillating character of the
dream ideas, the constant and primitive-like alternation of
presented and contrasting ideas, as well as the impossibility of
any lasting tension involved in restricted dream processes
without a leakage through inapposite associations, the influence
of suggestion can be but transitory.

Freud, in this recent work on dreaming, does not consider at
any length the relations of dreaming to insanity, merely indi¬
cating certain parallels. Such relation is, of course, of peculiar
interest to us, and we may well bring this review of dreams to
a close by a short summary of this branch of the subject.

Several pronouncements on the similarities or parallelisms
of dreams and insanity are familiar to us, e.g. % “ Insanity is an
enhancement of periodically recurring normal dream-states,”
“ Dreaming is a short insanity, insanity a long dream,” “ Find
out all about dreams and you will know all about insanity.”
Let us discuss these so-called parallels.

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1 9 1 5-]

BY F. STJOIIN BULLEN.

In both dreams and insanity, symbolism is the prominent
feature. It is favoured in the former by closure of the ordinary
channels of restricting sensations ; in the latter, in many cases,
by intense mental preoccupation, in which an abstract state is
fostered, and hallucinations, rather than normal perception,
occupy the attention.

Psychic dissociation, sometimes a cause of this, sometimes
an effect, is another essential factor in dreams of adults, and in
many forms of insanity, especially of degenerative kind. By
this disintegration segments of the psychic being are detached
and recombined into groups which appear external and foreign
to the main mass of the ego ; hence these dissociations are
always regarded as extraneous to the self, and acquire a
dramatic aspect. Subjective processes, however, always retain
their specific character in dreaming, so that consideration of,
and comments upon, the passing imagery is recognised in
thought as distinct from the dramatic representations which
are demarcated and regarded as real and objective. The
splitting-up of the personality of the dream goes to the extent
of allowing a detached portion of itself to be contemplated as an
actor in the drama, or appreciated in some disguise which it
may assume. But the division of personality is never so
marked as in certain forms of insanity where the foreign
portion assumes a dominating influence.

In both dreaming and insanity, in certain of its phases, there
is a reversion to primitive ways of thought, and to symbolism :
there is loss of distinction between waking and dreaming
thought ; there is ready translation of thought into imagery,
and a general rise in the perceptive element, and fall in the
conscious, or in true mental relationships. There is analogy,
too, between the regression of thought in dreaming, i.e>, the
return of the psychic current towards the mechanism of actual
perception, and the hallucinations of insanity. Hence it is
argued by Tanzi that the imagery of dreams is formed in
sensorial centres, and thus is hallucinatory in character. “ There
is,” he says, “ no ground for believing that dreams are dependent
on a mechanism different from that which determines the occur¬
rence of hallucinations in poisonings and in mental diseases.”
In this reversion, as H. Ellis indicates, we are on common
ground in the case of the child, the savage, and the madman.

Common to both dreaming and insanity is the fundamental
LXI. 3

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34 THE INTERPRETATION OF DREAMS, [Jan.,

element of ccenaesthesis. Organic sensations not only determine
the tone of the psychosis, but are transformed into an imagery
showing no direct relation to themselves. In both, spon¬
taneous attention alone prevails, based on emotional states ;
in both, apperception is in abeyance, and presentations are
accepted without criticism.

In both, paramnesiae are met with, not only in the sense of
recognition of a past impression, but in the reduction in value
of externally aroused perceptions, so that in states of psychic
enfeeblement memories, percepts, and ideas have equal value.
Thus, the experiences of others are transferred to ourselves, and,
as a result of false additions and subtractions of events, wrong
estimates of time, confounding of old and recent happenings,
and so forth, the medley of the dream and the semi-delirious
state of mental reductions bear resemblance.

In sleep and insanity alike ideas are presented opposite in
sentiment to those harboured in the waking state, and often
obverse to some latent wish. On the contrary, however, the
dream in sanity and madness, and delusion in the latter, may
express the wish in an undisguised manner.

Just as in madness, sudden phases of lucidity, or even
brilliant imagination, may occur, so, during dreams, the for¬
tuitous assemblage of ideas, freed from the bondage of external
impressions, may result in a clear, novel, and valuable product.
The liberty, too, of sensory images, and the influence of
emotion, may certainly convey an augury of some approaching
physical malady, whether of body or mind, to be set forth.
Hence the dream may likely serve as a prodrome to insanity,
and by its agitating influence on the emotions hasten its onset.
The same chance concourse of ideas in dreams may produce
the crystallisation of a delusion.

One has hardly ever failed to find in the work of that greatest
of all psychiatrists, Griesinger, illuminating remarks on any sub¬
jects, however modern in development, connected with insanity.
It is, therefore, interesting to revive his remarks on dreams
made over sixty years ago. He writes : “ The dream, like
insanity, receives tone from the governing disposition, which
may equally well be determined by the mental occurrences of
waking life as by changes of the organic states during sleep.
The ruling sentiments of pleasure and pain call for their corre¬
sponding images, in which objects, without form in themselves,

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1 9 1 5 •]

BY F. STJOHN BULLEN.

become sensuous clothed shapes, and what enters from without,
through the senses, meets in the dreamer, as in the insane
person, a centre preoccupied and filled with the given disposi¬
tion, and becomes perverted to, and construed in the sense of,
the ruling sentiments and ideas. Whilst, again, the same two¬
foldness of the personality, and the same emotions ensue when
groups of ideas and sentiments of unaccustomed hostile intent
stand opposed to the ego (repressed ideas). The dream, like
insanity, is occupied in transferring to the external world, in
dramatic form, the subjective imagery.” Griesinger comments on
the greater frequency of agreeable dreams in mental or bodily
exhaustion than in states of health, and he adds : “ The ideas
suppressed in waking life come forth strongly in dreams. To
the distressed individual come dreams of happiness and fortune,
or reunion with some lost loved one. So, also, in mental
disease, from the dark background of morbid painful emotion,
by sinking into a still deeper state of dreaming , the repressed
contending ideas and sentiments (i.e., bright visions of future
fortune and happiness) stand out, and the former mental misery
changes to the mirth of the maniac.” Thus the shock of
deprivation of some desire or possession leaves behind the
opposite idea or sentiment.

The advantage of Freud’s theories concerning dream states
is that they are constructed on the same plan as those dealing
with the waking life. His system, instead of merely furnishing
a series of observations on apparently disconnected, inapposite,
and shifting dream phantasies, is one, definite, and claiming a
reaction linked to cause in a definite manner. Freud’s sub¬
tility of explanation for the enigmatic variations of the dream
is remarkable, but it is impossible not to feel that his scheme
is often artificial, and its tendency to force a solution of mental
problems which is the result of mixture rather than of com¬
bination. It would seem as if he had claimed too much for
the dream-significance as a whole, whilst elucidating some of
its casual values. One cannot help speculating, too, as to how
far the supposed solutions arrived at by psycho-analysis, both
in the case of dreams and waking, are the result of suggestion
by the examiner. In the hazy state left by the dream, where
reminiscences and subsequent ideas are not well separable, the
errors which arise under paramnesia are probable ; the patient,
adjured to allow his imagination free play, may involuntarily

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36 THE INTERPRETATION OF DREAMS. [Jan.,

absorb suggestion, and, as in the case of the paranoiac, adopt
what Griesinger has termed the “ attempt at explanation ” with
complete satisfaction. It is true that Freud has recognised
this danger, but it does not appear to us that any sure safe¬
guard has been devised. Freud has naturally the same bias
as regards the sexual origin of many events in the dream as
he has shown elsewhere, and as for the most part he only deals
with his “Oedipus,” and other well-known complexes, in special
relation to the dream, there is no need to comment in this
place. This prominent leaning on the part of Freud has, in
this country, impeded the acceptance of his views and methods,
and epithets of pruriency and puritanism are mutually ex¬
changed. It is, however, too often lost sight of that Freud is
dealing with a people whose general materialism and attitude
towards sexual life is largely different to our own, and, more¬
over, with a special group of such people. From failure to
realise this, his views on the neuroses of childhood, for instance,
are misunderstood. The extraordinary protrusion of sex-
matters into the life of the Teuton, not only in adult but in
child-life, is shown clearly in Austin Harrison’s book, England
and Germany. Here is noted the large number of suicides
amongst young children, due, it is inferred, to precocious educa¬
tion, and premature awakening of love. Nearly every German
boy and girl have some “ grande passion ” ; the boy thinks of
feminine attributes and attractions as does the English youth
of ten years his senior. The majority of child suicides, writes
Harrison, are traceable to “ thwarted love.” Here, therefore, is
an atmosphere which is certainly alien to us, and, hence, not
reckoned with in our estimate of the statements made by the
Austro-German school of neurologists.

Probably an almost exclusive attributing of sexual motives
in the constitution of the neuroses is a passing cult of fashion,
whose advocates, like vultures, scent carrion from afar. The
more sceptical minds in this country may, on the contrary,
prefer to assume the passive role of the ostrich. The truth
may well be sought in the mean course. The attitude towards
Freud least just, and to ourselves most unprofitable, is that of
unqualified disparagement or indifference : his is one of the
greatest and most ingenious psychological minds of our time ;
it is only necessary to allow for a certain exuberance of imagi¬
nation, fertility of explanation, and arbitrariness in inference.

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1915 ] DRUG ADDICTION IN MENTAL DISORDER.

Drug Addiction in Relation to Mental Disorder. (}) By
Robert Armstrong-Jones, M.D., B.S., F.R.C.P.Lond.,
F.R.C.S.Eng., Medical Superintendent, London County
Asylum, Claybury ; Lecturer on Psychological Medicine,
St. Bartholomew’s Hospital ; and late Examiner in
Psychology and Mental Diseases to the University of
London.

We are at present meeting the most momentous, as well as
the most grave, crisis in our national history. No period in the
past has ever equalled the present to us as a race and an Empire
in the importance of its issues and destinies. Our existence as
a nation is at stake, and we are opposing with all our skill,
might and main, the fight of might against right. We are
engaged in a “ ruthless, relentless, and remorseless ” war, waged
with the cold, calculated scheming of a great business enter¬
prise, and before it is over the best of the lower and the middle
classes, the cultured, and the representatives of the professional
classes, the scientific and literary workers—those who are the
backbone of this country—will probably have to pass through
the ordeal of a great bereavement, much stress, and endure an
anxious if not an embarrassing poverty.

It may be well, therefore, that we should pause to inspect our
armour, even at this critical juncture, and attempt to discover,
if possible, any sources of weakness which may be subtly assail¬
ing us socially. Of late years, to a greater degree, many of the
masses, as well as the classes, have sought ease, and avoided
stress ; the theatre, the music hall, the ballet, and the cinema,
have been the diversions of the many, just as the light novel,
and the scrappy newspaper articles have been the popular
literary food ; in both cases a pabulum, it must be admitted,
suitably adapted for the morbidly neurotic temperament. It is
possible, however, and it is predicted by some, that the material
suffering entailed by a terrific struggle, such as we are witness¬
ing, and are sharing, on the continent of Europe at this
moment, may quicken men’s pulses, and stimulate their spiritual
and intellectual life into higher ideas and action. Be this as it
may, it is a fact that the present age, so far as progress is con¬
cerned, is one which has been pre-eminently characterised by
medical and sanitary advance, yet, notwithstanding the dis-

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DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

coveries of science, and with our increased medical knowledge,
there is more faith placed in quack remedies, and more money
spent on secret and useless nostrums, than ever before, and this
in spite of the findings of a special Committee of Inquiry 7 insti¬
tuted by the British Medical Association, and a Select Com¬
mittee on Patent and Proprietary Medicines appointed by the
Government, which have demonstrated the uselessness of many
of these vaunted recipes. Such an appreciation on the part of
an uninformed public, and such a belief in the efficacy of
empirical remedies to control symptoms and to cure ills, show
that we are in too great a hurry to decide for ourselves, being
only too ready to rely upon the clever but unscrupulous adver¬
tisements of the vendors of these so-called remedies. It also
accounts, in a measure, for the addiction to drugs which may
become a habit, and which then proves to be a serious menace
to the health of the best worker. The temporary relief from
pain, and the transient comfort obtained by the soothing effects
of certain sedatives (too often believed to be harmless in them¬
selves), is an excuse for the resort to drugs. Another excuse
for this addiction is said to be the quest for pleasure which has
characterised the present day, the age of neurasthenia, nervous
breakdown, and “ brain fag.’’ Pleasure has been sought every¬
where, but contentment is nowhere found! A further reason
may be found in the present constitution of human society 7 -
Thanks to a liberal system of education, women are enjoying a
larger measure of freedom to-day than they ever did before. It
is conceded to them that they have a right to order their lives
according to their own standard rather than according to early
Victorian notions, or those dictated to them by men. This has
had the effect of making women more independent and free.
They have become more the comrades and the companions of
men, they join in their sports and pastimes, and they are more
the equals of men in competition. They thus share men’s
frailties, and not seldom become a prey to their temptations
and weaknesses. For this reason, it is believed that women
drink more now than formerly 7 , and the eager workers among
them not infrequently 7 resort to drugs for “ help.” It is also
stated that women yield more readily 7 to the love of luxury 7 ,
excitement, and pleasure than men do, thus becoming more
self-indulgent, and, in consequence, flying to sedatives in order
to cope more readily with the artificial pleasures of social life.

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I9I5-]

BY ROBERT ARMSTRONG-JONES, M.D.

An American lady could only brace her nerves sufficiently to
undertake her social duties by taking freely of certain adver¬
tised tabloids. Dr. (now Sir) Seymour J. Sharkey wrote an
article in the Nineteenth Century many years ago in which he
stated that fashionable women resorted to morphia to such an
extent that they carried subcutaneous syringes which had been
jewelled to disguise their use.

The destructive effects of drugs upon the mind and body are
a high price to pay for soothing self-gratification, for their
sedative effect saps the best aims of the daily life as surely as it
extinguishes the high ideals and conceptions of the spiritual
life. The question—why do men and women take drugs ? may
be answered precisely in the same way as the question—why
do men and women drink ? Firstly, because drugs tend to
soothe the mind, and to make men and women oblivious to pain,
discomfort, and wretchedness, and to give the false idea of a
stimulating mental activity; but the happiness is short, the
mental energy transient, and the relief is brief. Stimulation is
followed by an opposite reaction, the refinement of the woman
is destroyed and the virility of the man is extinguished, the
material framework and the mental endowment are equally
shattered, duties are neglected, obligations are repudiated,
ambitions are unattained, and it is soon found that self-indul¬
gence has been gratified at too high a cost to the mental and
physical reserve. The “things that matter in life,” to quote a
recent expression, are no longer seen in their true perspective,
and the man or woman soon falls from the high standard
aimed at, which may have been at one time the goal within
view.

I have based this paper upon an experience of over forty
cases of the drug habit, and these are records of the asylum,
viz., of those who have practically become mental wrecks,
whose careers, bright and promising in many instances, have
been destroyed by a habit as insidious in its origin as it is destruc¬
tive in its effects. There are physicians present to-day who can
rightly claim to be leaders in their special branches, and their
experience will corroborate my own. It is known that, for
every case that comes into the asylum there are probably scores
outside the asylum who pander to the habit, and whose mental
and moral state is on the border-line of insanity; others are
insane, but their friends do all they possibly can to keep them

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DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

from the additional stigma of certification and incarceration.
The evidence of physicians, as well as of general practitioners, is
clear as to the disastrous effects following upon the indiscrimi¬
nate use of strong drugs, although probably only the repentant
sinner visits the consulting-room, and seeks for help to overcome
the thraldom. The medical man also naturally entertains a
professional delicacy as to publicity from the private case-book ;
moreover, the habit is a secret one, which makes it still more
difficult to deal with the matter publicly. The daily press in
addition bears witness to the case with which dangerous drugs
can be procured by the public, and to the sad loss of working
material consequent upon the drug habit in the community.
Headings such as the following are too numerous to quote : “A
Girl’s Downfall through Drugs.” A lady of good family, was
found guilty at the London Sessions to-day of theft, and her
downfall was due to taking drugs and drink. “The Drug
Habit.” He was finally brought up at Westminster, charged
with assault, etc., and was bound over; stated he would in
future give up the drug “ habit.” The coroners’ courts add
many more to their number. A medical coroner of expe¬
rience and distinction writes to me: “ I have had the deaths
of three doctors, one from opium taking, and one from morphia
injections; these two often used to come to inquests half in¬
sensible; a third died from addiction to tincture of nux vomica,
which he used to take every morning.”

That the drug habit is a wide-spread and serious evil is
further evidenced by the following statistics, kindly furnished
me by the Registrar-General, for the year 1912, the last year
for which the figures are available. The deaths from poisons
and poisonous vapours are given as 1,141 cases, of which 438
were from negligence or accident, and 696 from suicide.
He states that among the accidental deaths registered in
England and Wales, there were :

48 from opium, morphia, and
laudanum.

12 from veronal.

5 „ chlorodyne.

2 „ cocaine.

5 „ sulphonal.

4 „ chloral.

2 from narcotic (kind not
stated).

3 from trional.

1 „ paraldehyde.

1 ,, acetanilide (ante-

febrin).

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1915-] BY ROBERT ARMSTRONG-JONES, M.D.

And among the deaths from suicide were :

52 from opium, laudanum, 1 from cocaine,
and morphia. 1 „ sulphonal.

4 from veronal.

In addition to these, there were fourteen deaths from the
drug habit, viz. :

3 from opium, 1 from chlorodyne, 1 from a drug not

5 „ morphia, 1 „ paraldehyde, specified.

1 ,, laudanum, 2 „ nicotine, and

It is seen, both from this list, and from my own cases among
the private patients and the more educated at Claybury, that
the victims are from among the most energetic and useful
section of society, and it is mainly among the educated and
cultured that these cases are seen. It is advanced in regard to
these that there is a physical difference between the brain
pattern of the poorer and less educated as a class, when com¬
pared with that of the cultured brain-worker of the middle
classes. The complexity of the convolutional pattern in the
brains of the latter is in marked contrast to the simplicity and
the smaller weight of the brain and convolutions in the former,
and it is known that these physical differences carry with them
psychological and physiological concomitants, which imply a
higher sensitiveness, and a greater vulnerability in the physical
temperament and mental constitution of the better classes.
Drugs, as we learn both from reading and from experience,
exercise a peculiar fascination over the minds of brain-workers.
The quieting effect of opium, for instance, over worry and
anxiety, the feeling of bien faisancc, and the peculiar, dreamy
condition induced by it, when the imagination is fired and
quickened, and when ideas and images float before the mind
without effort, during which sensuous feelings, and the fabled
calm of the lotus-eater, are in marked contrast to the strong,
energetic activity of healthy and vigorous production.

The power to draw ideas from the subconscious into the field
of consciousness by the help of drugs is too great a temptation
to many a brain-worker; black coffee and green tea are familiar
and common examples; and this stimulation appeals with
particular force to the artistic temperament. Many are the
doctors, nurses, journalists, authors, barristers, literary men
and women, and even clergy, who have yielded to the insidious

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DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

temptation of resorting to drugs, and whose mental breakdown
has resulted from the habit. As is well known to every
physician practising in the department of mental diseases, the
brain-worker lives in a state of complex thought and emotion,
and the rapid and varied adjustment to a complicated environ¬
ment is often the measure of his success. The quick and
brilliant response to an immediate demand is the measure and
fulfilment of successful brain-work, but often when the eager
hand reaches to grasp the prize, it is plucked away by some
competitor better equipped for the purpose, or more highly
strung; and then it is that the strain of effort calls for the
stimulant, the “ brain tonic,” the nerve restorer, or the sedative.
The worker finds the drug has “toned” him up, or it has
afforded temporary relief from anxiety. He is either too busy
or too indifferent to obtain medical advice as to the real cause
of his trouble ; the drug has braced him up, and he resorts to
it again and again on the most flimsy pretext, until the day
comes when the drug habit, with all its sinister consequences,
has obtained the mastery over him. The following cases,
quoted from my own experience, support what I have to say:

(1) JEt. 33, single, a medical man; admitted excited, noisy, inco¬
herent, and violent; it took five men to take him to his ward. In his
certificate it stated he had visual illusions, and had glimpses of the
“ happy land.” He had slept badly and taken morphia to relieve head¬
ache, and his illness had been coming on for thirteen months. He
had been in Belhlem Hospital, and Dr. Stoddart kindly supplied me
with the information that, whilst in the reception room awaiting admis¬
sion, he swallowed a packet of morphia, and not knowing how much was
contained in the packet his stomach was washed out. Thirty grains were
found upon him, and seventeen more packets of powder, each labelled
“ two drachms.” Whilst at Bethlem the morphia was suddenly discon¬
tinued, but alternative sedatives, such as chloral, sulphonal, and hyoscine
were administered. Three months after admission into Claybury he
had a seizure, after which he rapidly became demented and exceedingly
feeble. Six weeks afterwards he had another seizure, and died. Upon
post-mortem examination syphilitic gummata were revealed in the brain.
No history.

(2) Tit. 35, single, a school-teacher; worried because she failed to
pass an examination. Took drugs, under medical advice, to a large
extent. Had two attacks of insanity, but recovered quickly when she
left off taking drugs—paraldehyde and sulphonal. A bright, fairly
well-educated, but neurotic woman, who developed sex delusions and
suicidal tendencies. No heredity.

(3) JE t. 39, married, a journalist; admitted with acute depression
and suicidal tendencies. He was restless and fidgety, sallow, and
wretched. He edited a paper at twenty-five, began to take morphia

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191 5-1

BY ROBERT ARMSTRONG-JONES, M.D.

three years before admission, and drank to excess. The habit
commenced after his mother’s death, which also occurred through
morphia, taken originally upon medical advice, and the same doctor
communicated the habit to him. His conduct became erratic, unreliable,
and he neglected his business, and left his wife and home. He had
voluntarily entered a “retreat” on three occasions. He was in the
habit of taking 20 gr. of morphia per day hypodermically, and after
admission two hypodermic needles were extracted from underneath the
skin of the right arm and left leg. He craved so intensely for morphia
that he stated he was ready to have his hand cut off, or his arm thrust
into a furnace, if only he could receive one subcutaneous injection of
morphia. He recovered mentally and was discharged, but he was
readmitted in a dirty, neglected, and miserable state two and a half years
afterwards. In four months he was again discharged recovered, and
after he left he wrote a deeply grateful letter for the kindness and
considerate attention he had received, but he added that it was
unnecessary for him to enlarge upon the futility of his efforts to break
the habit, as the man to perform such a deed was yet to be born.
Father insane (drink), mother’s side phthisis.

(4) A?A. 30, single, a doctor, who yielded to the morphia habit, which
destroyed his promising career. He was ultimately certified as insane,
and was received into an asylum. No history.

(5) ^Et. 32, single, a servant, had an attack of hysteria with depres¬
sion at the age of twenty-five, and was under treatment in Paris for one
and a half years. She was admitted to Claybury in 1912 with hysterical
symptoms, and suicidal tendencies. She was strange and suspicious,
deficient in self-control, and inclined to laugh and weep without cause.
She boasted she had been in the habit of taking “ headache powders,”
described them as “sedative” powders she obtained from the chemist,
paying sixpence for them ; she took them in order to do her work
properly, and to cure periodical depression. Thinks they brought her
to the asylum, where she has been for two years. Grandmother’s sister
was at Brentwood.

(6) vEt. 44, single, an authoress, states she nursed her mother
through a serious illness, and that she took laudanum in ounce doses to
aid her literary work, and this for long-continued periods. She was
admitted in a wretchedly depressed mental an<f*physical state, with
hallucinations of sight and hearing, but she improved greatly under
treatment, and she was a humorous, quick-witted, excitable, and lively
person of the artistic temperament. She gained a stone in weight, and
was discharged recovered in three months. A statement was made by
a doctor that she had been a drug-taker for long periods. Paternal
relative in asylum, paternal uncle drank, paternal grandmother burnt to
death in a fit.

(7) A'A. 44, single, a milliner, described as an habitual sedative-taker
and a drinker. She mostly took chloroform and sedatives for neuralgia.
She states she obtained her sedatives from the chemist, and has taken
drugs regularly for insomnia. She was admitted in a depressed state,
having nearly destroyed herself with chloroform. She is an educated
and bright woman, but suffers from loss of memory. Has been in
Claybury nine months, and is still under treatment. Father drank,

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44 DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

maternal grandfather phthisis, maternal grandmother cancer; paternal
side not answered.

(8) Ait. 39, married, a lithographic artist, of marked ability, did
unaccustomed night-work, and suffered much stress, and except under
the influence of bromides he obtained no sleep. Admitted with
marked depression and sleeplessness, he was excited, emotional, and
restless, and looked very ill. He had suffered with insomnia for years,
and habitually took bromides. Recovered in three months, and gained
over a stone in weight. No heredity,

(9) Ait. 39, single, an insurance clerk, stated to have suffered from
severe insomnia for three years, and to have taken a considerable
amount of sulphonal, also lately drank two ounces of whisky nightly
with the object of getting sleep, although he was until then a life-
abstainer. He was admitted in a shaky physical state, and a feeling of
being gradually run down; mentally he was depressed, restless, walking
up and down the room, and fearing he was “going mad,” but was
without delusions or hallucinations. His memory for recent events
seemed to be failing, and he was unable to carry on the small details
necessary for his occupation. Was discharged recovered under three
months. Sister at the Manor Asylum, mother attempted suicide twice,
maternal aunt died at Claybury.

(10) vEt. 34, married, a cleik in the Bank of England, with a
pleasing, intelligent manner, but with marked symptoms of depression,
and delusions of a self-acusing character. Took laudanum, and once
nearly ended his life thereby. He complained of having had no sleep
for months before admission, and had been in the habit of secretly
taking drugs to induce sleep. The suppression of this factor and others
in his private life caused him to worry and brood as to his wife’s con¬
fidence in him, and attachment towards him, and he was certified as
insane, but recovered after four months’ treatment. Patient’s father
drowned himself from a ship, mother had sunstroke and insanity, and
finally drowned herself at Brighton.

(11) Ait. 25, single, a civil engineering student at King’s College,
took trional for twelve months before admission. He was suffering
from marked depression and listlessness, and a want of interest in his
surroundings and himself, he had been sleepless and worried, and,
being of a highly sensitive disposition, became despondent about his
work and prospects. Previously in Camberwell House. No heredity.

(r2) Ait. 52, married, a cabinet maker, described as a temperate
man, but had suffered from influenza, followed by insomnia. Took
veronal, and developed delusions of suspicions against his wife. His
memory was good, and he reacted readily to questions, but he became
depressed, and before admission had been treated as an out-patient for
neurasthenia at St. Bartholomew’s Hospital. His suspicions against
his wife increased, and he bought veronal without a prescription, and
once almost died from an overdose, to hide his supposed shame. He
was admitted to Claybury in 1914, and was discharged recovered in
three months. No history.

(13) /Et. 64, married, a medical practitioner, who had practised in
Somerset and Essex ; took opium three or four years before admission
to relieve attacks of ague, and this was followed by drinking brandy.

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PRINCETON UNIVERSITY

*915.]

BY ROBERT ARMSTRONG-JONES, M.D.

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He was described as energetic and industrious until his indulgence
brought a general weakening of mental power, and with this some
neuritis, and consequent visual and cutaneous hallucinations. Admitted
to Claybury as a pauper patient in 1914. Father died of paralysis,
maternal uncle drink.

(14) vEt. 60, widow, described as a well-educated, quick person,
who had obtained her livelihood as a needlewoman. She was very
nervous and easily disturbed, suffered from periodic headaches, and was
very susceptible to outward stimuli. She was depressed and suicidal on
admission in 1911, stated she was unable to sleep, and had recourse to
sedatives, having been an habitual bromide-taker. She nearly ended
her life with bromide of potassium and chloroform before admission,
and had written to the coroner in view of her own inquest. She
recovered in nine months. Father drank ; husband also died through
alcohol.

(15) /Et. 26, single, a cook; admitted suffering from extreme melan¬
cholia, with delusions of persecution. She had taken large quantities
of laudanum, which she took “to drown her sorrow and disgrace,” and
because she was “unfortunate.” She lost all moral control, and had
several illegimate children. No history.

(16) ALt. 56, widow of independent means, admitted with delusions
that she was the victim of a conspiracy to defraud her of property, and
that there was a deeply-laid plot against her. Had taken chlorodyne
habitually and to excess for three or four years ; she would take three
or four bottles a week of Freeman’s (45. 6 d. size), and her mental
symptoms had been coming on since. She became self neglectful of
her person, and of her domestic duties ; used to remain awake at
night, but slept so soundly by day that she could only be awakened with
difficulty. She recovered under treatment in eleven months. Father
very intemperate.

(17) JFa. 25, married, a board-school teacher, and an educated
young woman ; took chloral, bromides, sal volatile, and alcohol. She
developed hallucinations of sight and heating, and feared she might
hurt herself or others. She became separated from her husband—a
musician—neglected her child and home, and sank lower and lower
until she lost all moral control and sense of right and wrong. She used
to boast that she had a trap-door in the floor of her bedroom full of
chlorodyne bottles. She was discharged recovered, but subsequently
relapsed again, becoming a confirmed drunkard, and would drink or
take anything she could get. Mother insane. Father and brother
drink.

(18) -Et. 55, single, a pianoforte finisher, a life abstainer from alcohol.
Was admitted suffering from delusions that he had been drugged by a
relative, and that he was the victim of the “ black art mystery.” He
had suffered from sleeplessness, and for years had been the victim of the
chlorodyne habit. He had hallucinations of taste, vision, and hearing,
and imagined those he looked for had some harm through him, so he
wore glasses to prevent the effect. Admitted in 1911, and discharged
recovered after five months’ treatment. Sister died in Claybury.

(19) *Et. 20, a traveller, was a bright and quick boy at school. He
was of a reserved and unsociable disposition, disinclined for any games,

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Original from

PRINCETON UNIVERSITY

DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

became addicted to the morphia habit for “a long time” as a youth,
and this craving extended to any soothing drug he could procure,
although he was never addicted to drink. He went out to Canada, but
failed there, and returned home again to indulge in morphia tabloids,
which he himself purchased. His father attributes his failure to the
drug habit, and he is now incurably insane. Maternal grandfather
and an aunt drank, as also a paternal uncle. Maternal grandfather died
from phthisis. Cousin in Bexley Asylum.

(20) yEt. 52, married, a chemist’s assistant; he had suffered from an
attack of insanity in early life. He was admitted in an acutely despon¬
dent state, with suicidal tendencies. He had suffered from marked
restlessness and loss of sleep, and was stated by his friends to have been
subject to the drug habit, and drugs had to be kept away from him.
He was self-accusing, depressed, and miserable. Admitted to Claybury
in 1904, and discharged recovered after a residence of two and a half
years. No heredity.

(21) yEt. 38, single, an author; admitted in a profoundly depressed
state, with symptoms of marked physical and mental exhaustion. He
is a member of a talented and able family, his relatives being distin¬
guished in both business and scholarship. He is the author of several
published novels, and was possibly on the way to fame. He states that
lie worked hard and continuously at high pressure, and that he indulged
in nerve tonics to keep it up. He became depressed, fatigued, and
sleepless, and was certified to be insane. He is now confirmed in his
insanity. Maternal uncle phthisis, mother died of cancer.

(22) yEt. 52, married, a captain in the Army Veterinary Corps, a
very intelligent man with a University career, whose whole ambition
was in his profession. Stated to have had a fall from his horse, and had
been subject to fits ; he lost his nerve, fretted and worried over domestic
matters and trouble through wife’s divorce, and was compelled to leave
the Service. He took veronal to induce sleep, and was eventually
certified to be insane. No heredity.

(23) yEt. 43, married, a coachman; admitted in a greatly impaired
bodily condition, and he looked ill and dyspeptic. The skin of the
abdomen and both arms was much scarred from the effects of the
morphia hypodermic syringe ; the habit, originally started by his doctor,
had been continued for tsvelve months before admission. He was
deluded, and had hallucinations of taste and smell. Discharged
recovered in seven months. Sister drank, and a heredity of “ fits or
paralysis ” stated.

(24) yEt. 35, married, a steward, Royal Naval Reserve; had travelled
about the world a good deal when on the China station ; worried greatly
over business affairs, backwards and forwards to Paris and places
abroad, making purchases for his business as a fancy goods dealer. He
was described as of very steady habits, but most anxious to get on, and
ambitious for his family. He became depressed, introspective, a prey to
ego-centric ideas, and began to take sleeping draughts of all kinds without
medical advice; he became reduced in health, developed neurasthenia,
and got into a “ brooding,” low condition, having later to be certified as
he became sleepless and suspicious, wandering about the house with a
drawn sword, thinking strange people were about who wanted to take

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PRINCETON UNIVERSITY

1915-] BY ROBERT ARMSTRONG-JONES, M.O. 47

his life. He recovered within two months. Sister and a paternal uncle
insane.

(25) JEt. 62, widow of a clerk. She took antipon, and Mrs. Seymour’s
reducing tablets—many pounds’ worth, and got into mental ill-heallh,
and became deluded, garrulous, and boastful. She lost all self-control,
and got into the hands of the police through stealing some feathers she
fancied. She was certified to be insane. She remains under treatment
and has now been about three months under care, having somewhat
improved in the meantime. Sister committed suicide.

(26) JE t. 58, single, an authoress and artist, a peer’s niece; she was
recommended by her doctor to take paraldehyde for sleeplessness. She
became a victim to the drug, and took from one to two ounces every
night. She used to hide bottles under her pillow or bed, and ordered
it herself from the chemists. She became suspicious, deluded, suicidal,
and gradually lost her reason, having to be certified and placed in an
asylum, where she died. No history.

(27) Ait. 47, married, a nurse; admitted with delusions of sex, of
conspiracy, and persecution. She began by taking chlorodyne, and then
morphia. Discharged recovered in two months. Was re-admitted
three months later, having now yielded to alcoholic intemperance, but
again after two months she was discharged recovered. No history.

(28) Ait. 30, single, a lady journalist, of American nationality, with a
prepossessing manner and striking appearance. She was admitted in a
deluded, persecuted state of mind, confused, egotistical, and muttering ;
she was in poor condition and wretchedly clad, having been found
wandering by the police. She stated she had been the victim of
morphia, taken for sleeplessness. After about ten months’ treatment
she was discharged recovered. No history.

(29) ^t. 56, married, a nurse; on admission she was self-accusing,
believing she had committed a great crime; she was depressed and
suicidal, and only wanted to “ sleep it away.” She had been a nurse in
a public asylum, and had obtained her pension; whilst on night-duty
she had been allowed sedatives to induce sleep by day. She sighed
and begged and craved for morphia, as she had taken it, she said, for
many years. After seven months she was discharged recovered, but
eight months afterwards she relapsed, was readmitted, and died incur¬
ably insane after six years. No history.

(30) Ait. 37, married, a medical practitioner; was admitted in 1912
in a depressed, dull, stolid condition, making no veibal response to
questions, and resisting and resenting attentions for his care. He was
of the artistic and refined temperament, he contracted the morphia
habit, and also drank. He suffered from both visual and aural hallucina¬
tions, and suspected poisoning; his memory become affected, but he
regained this under treatment, but the period of his illness remained a
blank to him. He lost his professional reputation and practice, was
certified insane and taken to a pauper asylum, but he recovered com¬
pletely in six months. No history.

(31) Ait. 62, married, a clergyman ; was admitted in an untidy, self-
neglected, and restless state, was uncontrollable and very excited. He
was stated to have been in the habit of taking drugs to induce sleep, but
no particulars were elicited in the history, but he had been sleepless for

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PRINCETON UNIVERSITY

DRUG ADDICTION IN MENTAL DISORDER, [Jail.,

months before admission. He had previously suffered from similar
attacks of mental breakdown. He had been a most capable and
respected man, but had gradually fallen lower and lower into a state of
incurable mental decay, and died in the asylum. Three brothers and
three sisters insane, father drank, and maternal side an eccentric
family.

(32) /Et. 43, married, a lady dentist; admitted in a depressed and
confused slate, exceedingly nervous, trembling, and with suicidal
tendencies. She complained of headache and vague lumbar pains, for
which she had taken morphia; she had been advised to try opium
cigarettes, which only produced nausea, and aggravated the headaches.
She then took morphia in the form of draughts, which relieved the
insomnia and pain; the quantity was gradually increased to 4 gr. doses,
after which she said she enjoyed “delightful dreams,” “compared to
which fairyland was the merest prose.” She increased the dose to 6 gr.,
often taking this in champagne, the result being (in her own words, in
a letter after convalescence) that she saw things exactly as she wanted
to. She was discharged recovered after four months’ tieatment, but
seven years later she was readmitted, and remained under treatment
another year. Was again admitted, and died insane. No history.

(33) Alt. 43, married, a pianoforte-maker; admitted with aural and
visual hallucinations, as well as marked depression and suicidal tenden¬
cies. Two months before admission he lost his work owing to a
gradual and increasing self-neglect, and thereby lost the means to buy
the drug, in consequence of which he “ lost heart ” and wandered about
half-starved. He could not sleep, became very nervous, irritable, and
depressed, complained of acute neuralgia. In four weeks he began to
improve under treatment, stated he felt a new man, and was discharged
recovered in three months. Four years before admission he began to
take chlorodyne for toothache; this he found was too expensive, and
he bought laudanum, at first in small doses, which he finally increased
to four ounces daily. Sister in Colney Hatch in 1891.

(34) fiLt. 33, single, an estate agent, but his leisure time was given
up to literary and artistic pursuits. He was admitted with delusions of
suspicion against his own immediate relatives, whom he thought were
against him, and he wished to die. His memory for recent events
failed, and he could not be relied upon in business; he was stated to
have been for three years before admission almost constantly in the
habit of using morphia, cocaine, and atropine hypodermically, and his
thighs were marked with the scars of hypodermic needles. His muscles
were tremulous and he was in a very impaired state of physical nutrition ;
he used about nine grains a day of morphia w ith atropine—he stated,
to lessen the depressing effects—but he also used about five grains a day
of cocaine. He was seriously ill on admission with diarrhoea and
sickness, for which he had “digestive” medicines and maltine. He
said he felt acutely miserable, despondent and cold, but after the
“ craving ” ceased he felt much better. He was admitted in 1905, was
discharged recovered in three months. He relapsed after three years,
having used six grains of morphia and cocaine, and has become incurably
insane. No history.

(35) AL t. 30, a journalist, single ; educated, bright, and quick, had

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PRINCETON UNIVERSITY

1 9 1 5-3

BY ROBERT ARMSTRONG-JONES, M.D.

been in New York and Paris, and evidently well acquainted with the
London and Paris restaurants. He was the victim of large amounts of
cocaine and morphia, and up to eight grains a day. He had been
engaged as the French representative of a newspaper, and followed the
French Foreign Legion in North Africa. Had quick ideation, and was
full of projects and plans. Was admitted in a voluble, boastful, and
irresponsible state, saying he had great wealth, and had been ordering
things at various shops for which he was unable to pay. He was
confused, and impulsively impatient, speaking rapidly and clearly. He
was admitted in a state of confusional sub-acute mania, very run down,
generally exhausted, and sleeping badly. Had some cutaneous anres-
thesia. Was discharged recovered, after six months’ treatment, in 1914.
Grandfather drank, but no history.

(36) ^Ft. 39, single, a medical practitioner, and a former student of
St. Bartholomew’s Hospital; well connected, and with every prospect
of professional success. YVas admitted with numerous scars and
pigmented spots from the use of the hypodermic syringe on trunk and
limbs. States he became the victim of morphia and cocaine, and that
in consequence he su/Tered from mental breakdown with marked visual
hallucinations; he had great difficulty in concentrating his mind on
anything said to him, and he was depressed and listless. States he took
morphia in order to be “ wound up,” as he did better work after its
use, and that he took about eight grains a day. His moral sense, and
ideas of duty and the rights of others, became greatly deterioriated, and
he has become incurably insane. Paternal uncle and two cousins
insane.

(37) JE t. 45, married, a chemist, described as a highly sensitive, well-
educated pharmacist; admitted to Claybury, 1910, but had been detained
ten years before for one month in another asylum through “ drink.”
Started the morphia habit shortly after his discharge. He was admitted
in a depressed, emotional state, being solitary in his habits, and disin¬
clined to be sociable. His memory was good, but he was the subject of
conflicting aural hallucinations. He had travelled a great deal abroad,
having been engaged as a dispenser at Biarritz, Paris, Nice, Geneva,
Jersey, etc. He states he commenced with gum opii, taking two grains,
but later took nine grains of morphia a day, having taken it at first to
obtain sleep, and later for its specific effects. He recovered in six
months, and left for work abroad, but subsequently took morphia again
and relapsed. Paternal aunt insane, some collaterals “ delicate,” and
mother died of cancer.

(38) M t. 42, a typist, married, but separated from husband, who
was an officer in the Army, and the son of a general. She herself had
been educated at the Royal School for Officers’ Daughters, at Bath.
She was an habitual drug taker for years. Her mental symptoms
were an exaggerated idea of her own importance, coupled with vague
suspicions and threats when not able to get her own way. She was
emotional, and there were suicidal tendencies. She was an adept at
writing begging-letters. No history.

(39) JEt. 27, single, an artist; was a bright, clever boy, and head of the
school at Shrewsbury in science. He devoted himself to art, at which
he worked conscientiously and hard ; he went to study in Paris, and

LXI. 4

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PRINCETON UNIVERSITY

Table i.— Drugs and Insanity : Details oj Cases.

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50 DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

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PRINCETON UNIVERSITY

52 DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

exhibited his work in the Salon, and was probably destined to become
distinguished. He, however, took to the ether habit, and developed
visual hallucinations, and delusion of suspicion as to spies and being
hypnotised; he confused the identity of persons about him, became
self-neglectful, heedless, and indifferent, and is now a confirmed lunatic.
No heredity. Paternal aunt died of phthisis.

(40) Ait. 52, married, formerly a surgeon under the Government of
India, and a fair artist—some of his work having appeared in scientific
drawings. He started the drug habit by taking morphia and cannabis
indica two years before admission. His memory became impaired,
and his manner irritable and brooding, with passionate outbursts, and
he suffered from visual illusions, ending in delusions of persecution.
He was found guilty at the Central Criminal Court of forging a cheque—
as “guilty, but insane”—and was ordered to be detained during His
Majesty’s pleasure. Is now an inmate of a public asylum. Elder
brother drank.

(41) Ait. 35, single, a responsible official in a large public institution,
with every prospect of further promotion. SIiq began to take chloral
and bromide draughts, then paraldehyde, and subsequently drink. She
lost her sense of self-respect, and, in spite of various warnings, deliberately
ruined her own career. She was subsequently tried for an offence at
Quarter Sessions, and sentenced to imprisonment, her downfall being
distinctly traceable to yielding to the seduction of sedatives, which
demoralised her and destroyed her sense of responsibility. No history.

Table 2 . —Summary of Heredity.

No.

Cases.

Insanity,

Alcohol.

F.pilepsy.

Paralysis.

Phthisis,

Cancer.

heredity.

history.

Form of drug taken.

Morphia .

„ and cocaine

„ ,, and atropine i

„ „ opium cigarettes . i

„ ,, cannabis indica . l

„ „ chlorodyne . . i

Chlorodyne . . . . I

„ (Freeman’s) . . i

„ and laudanum . i

Laudanum .... 3

Chloroform . . . . 1

„ and bromide of potas¬
sium ..... 1

Bromides . . . . . 1

„ chloral and sal volatile 1
„ „ paraldehyde 1

No. of
instances.

1 Paraldehyde , . . . i

j Opium.1

I Veronal ..... 2

I Trional ..... 1

Sulphonal . . . . 1

Ether.1

“ Nerve tonics ” . . . 1

" Headache powders ” . .1

“ Drugs for sleep ”, . .2

" Sleeping draughts of all kinds” 1

“ Antipon ” and “ Mrs. Seymour's
Reducing Powders ” . . j

Not stated .... 2

Total . . . .41

Table 3 .

No. of
nstnnces.

Form of drug taken.

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Of these forty-one cases, all except one became insane and
were certified. As regards sex, and occupation, and civil state,
twenty-five were males and sixteen females, although it is stated
that women are more often the victims of drugs than men.
The fact that there is accommodation at Claybury for sixty
male private patients and none for females possibly accounts
for the figures quoted here. Three were widows, and the rest
were evenly divided between married and single. The occupa¬
tions varied considerably, but they were those, in the main, of
the better educated, and indicated the brain rather than the
manual worker. Six were medical men, three were nurses,
and one was a lady dentist; two were chemists or druggists,
two were teachers, three were journalists, three were authors,
two were artists, and there were among them representatives of
the clergy, army officers of the professional class, students, and
those engaged in commercial pursuits.

It is suggested that propinquity to sedatives, a knowledge of
their use, and opportunities for indulgence arc causes of addic¬
tion, and there is no doubt that this is true, for the greater
number were doctors and nurses, over one-third of my cases
being in daily contact with drugs. It is encouraging to believe
from this statement that legislation of a restrictive or prohibitive
character might be a preventive, or a bar to self-indulgence, as
it is only too true that many of those addicted to the habit will
improve, and to a great extent regain their mental balance,
when the drug is withdrawn, as of necessity it must be when
they are under care in asylums.

The form of the drug taken is much more frequently an
opium derivative than any other kind, and morphia heads the
list. More than half my cases took morphia, chlorodyne, or
laudanum, morphia being the drug in fifteen out of the twenty-
one cases of opium or its derivatives. Some took opiates by the
mouth, drinking it as laudanum or chlorodyne, and others
used the hypodermic syringe as well as drinking the solution
of morphia. Cocaine, either alone or with cannabis indica or
atropine, was also taken. The new synthetic drugs caused
several persons to become victims, such as veronal, trional, and
sulphonal; but sedatives, “ sleeping draughts,” “ nerve tonics,”
and "headache powders” also figured, and one case was dis¬
tinctly attributable by the patient herself to the reducing bodily
effects of “ Antipon,” and of " Mrs. Seymour’s Reducing

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Tablets.” Chloral, paraldehyde, and the bromides were con¬
sidered to be the cause of mental breakdown in the case of five
persons. “ Drugs for sleep ” was the generic term used by one,
and “sleeping draughts of all kinds,” without definite specifica¬
tion, the description in another. Chloroform vapour was used
in two cases, and ether in one, in another smoking opium was
the method and the sedative. The largest quantity of morphia
taken was stated to be 20 gr. per day, afterwards increased to
50 gr. of the acetate. In fact, the limitation of the quantity
generally depended upon the pecuniary position of the victim,
and the quantity of morphia taken was generally as much as the
means would allow. In some of the morphia cases the limbs
and the body were literally scarred all over by the hypodermic
syringe, the skin of both arms, the abdomen, and thighs being
often pigmented through and through by the needle. One case
took 4 o z. of laudanum for a daily dose, and another drank
bottles of chlorodyne as often as she could afford to buy them.

It is notable that the average age when they were brought
into the asylum was forty years for males and forty-three for
females, an age when the struggle to maintain the position
reached was the most severe, the most trying, and the keenest,
when every accession of energy was not only most useful, but
of vital importance for actual existence, a period for females
which is also the most critical from the standpoint of mental
and physical resistance.

It is of interest that there is a family history of insanity, of
epilepsy, or of paralysis, or an inheritance of phthisis or cancer
in the families of considerably over 70 per cent, of the total
number of my cases, which certainly shows the neurotic tem¬
perament of drug victims, and which allows the question to be
put whether drug-takers are not primarily insane, and not that
the drug habit itself induces insanity.

Two of the cases suffered from epilepsy, but they had been
very able persons. In most of the cases, melancholia, or
insanity of the depressed type, was the form of mental disorder,
and this was the case in 75 per cent, of the total. The reason
why these cases are brought into asylums is mainly through
attempts at self-destruction, or from the fear of their friends
that this may happen, and the frequency of a suicidal tendency,
which was observed in 57 per cent., confirms this statement.
Four of the cases were of the form described as moral insanity,

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and it is difficult, perhaps, to differentiate cause and effect in
some of these cases; but I am inclined to the opinion that
moral turpitude is one of the chief mental effects of long indul¬
gence in sedative drugs of all kinds; mostly is this the case
with the morphia-taker, as it is well known to be with the
drunkard. The form moral insanity implies a loss of the finer
feelings, a blunting of the conscience, a disregard for truth,
and an unreliability which makes it impossible for the victims
to enjoy the confidence of employers, or even the regard of
their friends and relatives. The moral obliquity, and the bare¬
faced un-veracity in this class are marked features; but the
progress of deterioration is a slow one, culminating, however,
in inextricable destruction, the mental state eventually ending
in fatuous listlessness, and the physical state in emaciation,
decay, and death.

In so far as the prospect of recovery goes, much must depend
upon the'firmness, the tact, and skill of those in charge of the
patient; but if the drug is withheld, and liberal nourishment
is insisted upon, the prognosis is on the whole favourable.
Out of my forty-one cases, twenty-two recovered; two were
improved; three were transferred elsewhere; and four died.
Nine continue to be resident and under treatment in the asylum.
As may be seen from my cases, not a few have started the drug
habit from a misapprehension in regard to medical advice;
some, it may be said, whilst undergoing medical treatment,
although with more truth it might be stated the sufferer has
become a victim through his own effort to undertake his own
relief. Indeed, the casual resort to a drug to obtain relief from
a trivial ailment is often the starting-point in a downward
career of drug-taking, and there is no doubt whatever that the
habit, which is almost universal, of taking drugs for trivial
disorders is a very serious one and calls for intervention. The
progress of pharmacy has made it possible for the general
public to treat itself to-day in a way that was impossible in a
previous generation, for new drugs and new preparations have
been invented which are found to relieve certain symptoms
with apparent success, and such trivial symptoms as headache,
slight insomnia, restlessness, pains, and neuralgia are often thus
relieved without medical advice. But these apparently trivial
symptoms may be the serious signs of severe mental or physical
overstrain, and the drugs taken often mask the symptoms of

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an underlying and undiagnosed disease, the recognition and
treatment of which by a doctor might quickly cure ; the disease,
however, continues until it is no longer curable, and the
symptoms which might have been allayed by attacking the
cause remain until there is absolutely no remedy and no cure.
Unfortunately, the sedatives, refreshers, cordials, headache
powders, and other nostrums tend to produce a habit that is
far more distressing than the symptoms that have led to their
adoption, and this habit brings in its train infinitely more
serious consequences. The transient feeling of stimulation, as
has been stated, is followed by exhaustion, the natural forces
of the body have been lowered to such an extent that the victim
drifts into permanent ill-health, and the toxins within the
organism begin to impair the digestive and other functions ;
they weaken the heart’s action and lower the whole of the
bodily and mental functions, so that a cure now becomes almost,
if not quite, impossible.

The symptoms of drug-taking necessarily depend upon the
kind of drug used, and of these morphia is probably the
commonest, either alone or in the form of chlorodyne or some
other anodyne patent medicine ; next come cocaine, chloral,
and the bromides, then possibly chloroform, veronal, ether,
trional, sulphonal, and paraldehyde; “ headache powders,” anti¬
pyrin, aspirin, and phenacetin also figure, and, curiously
enough, so does “ Antipon,” and “Mrs. Seymour’s Reducing
Powders.” I have had the opportunity recently of demon¬
strating several of these patients to the Lunacy Commissioners
of the Board of Control and to Sir James Crichton Browne, the
Lord Chancellor’s Visitor. Their symptoms varied from visual
and aural hallucinations to delusions of suspicion, persecution,
and of grandeur; the mental reduction was of the nature of a
dissolution, the characters last attained were the first to dis¬
appear, the appreciation of right and wrong, the fine regard
for others, and the feeling of self-respect were diminished, and
social degradation was complete ; the will had lost its pow r er
and the appeal of the home, of dependents, of the wife, or of
children, had ceased to have force, and there was complete
indifference to distress ; the sentiment of love, and the emotion
of shame, of pride of place and of ambition for position, had
ceased to move conduct. The whole mind had become
weakened, and in addition to the mental symptoms there was

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injured health, bodily weakness, tremors, a failure of muscular
control, and a total inability for the exercise of energy and
activity. Misery, degradation, and pecuniary damage were the
inevitable result, and although most of these cases recovered
under treatment, many of them died. The loss of moral
control in those who did recover was such that once the
restraint and the supervision provided by compulsory detention
in the asylum ceased, after the patient was discharged, the case
frequently relapsed.

It is interesting to discuss the relation of the drug-habit to
insanity. Is the drug-taking habit—for instance, the indulgence
in morphia—to be looked upon as an affliction beyond the power
of the will to modify or to control; is it a disease to be sympa¬
thised with, and treated as one in regard to which the patient is
powerless to act ? Or, on the other hand, is it a pleasure-giving
vice, to be treated by punitive methods ? Dr. C. A. Mercier ( 2 )
looks upon all acts which are committed by persons who err
against their own interests and against themselves as dependent
upon some incapacity in the wrong-doer, which he describes as
a failure in that person of the capacity to forego an immediate
satisfaction for the sake of some future good. Such a person, he
states, is unable to limit his own freedom of action for the benefit
of the community to which he belongs; and, Dr. Mercier further
adds, it is an incapacity of control, a lack of inhibition, a want
of self-restraint, an inability to restrict undue freedom of action,
and in so far as the acts tend to disorganise the body politic,
or to bring about the dissolution of society, such indulgences
may be insane vices, or crimes against society. It is now a
crime against society to be drunk in a public place, but previous
to the Licensing Act of 1902 this was not so.

The exact line that demarcates vice from insanity is hard to
fix, for the difference between the two is merely a question of
degree, and this degree is somewhat arbitrary. The person
who takes drugs with the view of obtaining immediate, although
transient, relief at the cost of future mental or physical health
is probably thoroughly vicious, but he is not thereby insane.
But the person who indulges in the drug-habit to the detri¬
ment of himself, and of those dependent upon him, whose affairs
are being neglected, whose health is being ruined, and to whom
every appeal to mend his ways is futile; whose family, through
his indulgence, is suffering from the deprivation of those neces-

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saries to which they are entitled, such a person is certainly, in
my opinion, insane. The test of insanity, in this instance, as
Dr. Mercier points out, is the gravity or the magnitude of the
difference between the immediate advantages to be gained, and
the future benefits which are thus being forfeited. The question
arises, therefore, are those persons insane who indulge in drug¬
taking to the degree described above ?

Before this question is answered, let us consider if some
classification of drug-takers is possible. It is generally agreed
that there are grades and classes of these. Firstly, there is the
person who prescribes for himself, who is in the habit of taking
drugs or sedatives only in small and occasional doses—the
casual drug-taker, who is certainly not insane. Secondly, there
is the person who has periodic bouts of drinking or drug¬
taking; he takes bottles of spirits, chlorodyne, paraldehyde,
bromides, or opium, or quantities of morphia or other drugs;
he yields to a definite physical craving, and indulges in debauch
after debauch, but in the interval between the outbreaks—
which tend to become shorter and shorter—he is competent
and able. Then, thirdly, and recruited from either of the pre¬
vious classes, are those who gradually yield to the effects of drink
or drugs until their physical and mental health is ruined, and
they find themselves in the workhouse or the asylum. Such cases
are known to every doctor, the habit has grown upon them ; it
possibly began from a morbid curiosity, or from a prescription
of the medical man ? The drug-takers of this class may well
be described as habitual ones. Before the drug was taken the
mind was free from any intellectual defect or disorder, but
since then there has been a gradual, yet progressive, deteriora¬
tion of mind, and, in spite of the fact that the victim knew
that he was advancing towards his own destruction, and that
his indulgence was leading him to inevitable disaster to himself
and those who might be dependent upon him, he pursued his
own undoing. When the will-power is insufficient to withstand
the habit, when the craving leads to taking larger and larger
doses, when it has become a master passion against which the
victim is unable to offer his resistance, then conduct can only
be described as insane. There is no doubt that the mind has
become diseased in these persons, and the sufferer is insane.
Sir George Savage pointed this out in an able article in Clifford
Allbutt’s System of Medicine, and he pointed out that many of

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BY ROBERT ARMSTRONG-JONES, M.D.

this class were of the neurotic type, arising from an unstable
stock, and belonging to insane relatives. My own experience
supports this view, and I am convinced that the only suitable
treatment for such cases is compulsorydetention for long periods,
if possible, in an asylum, and in many instances the sufferer is
only too glad to be thus under care, and to obtain a cure; but
he is helpless when directing his own treatment. It is essential
for this class that the battle of demorphinisation—as Charcot
has termed it—should be fought out where it is impossible
to obtain the drug, where discipline is firm, and where the
diseased mind can be trained and encouraged into healthy
thought and channels under a trained staff.

It has been asked by some whether the drug habit is ever
the actual cause of insanity, and it has been suggested whether
such a habit should not be described as a contributory rather
than the actual causative factor? Apart from the fact that
so complicated a condition as insanity is rarely the product
of one factor, and that it is now fashionable to refer to cor¬
relative, co-ordinate, contributory, or associative factors, the
best answer to this is, that when the drug is withdrawn the
symptoms abate, and the mind is restored, the patient is dis¬
charged from the asylum or home recovered. But with the
next relapse into drug-taking the whole train of symptoms
reappear with all the former evils in their train. It is only too
well known how difficult it is for sufferers from the drug-habit
to control their own destiny by abstention. Coleridge went
so far as to hire men to prevent his getting opium, and yet he
dismissed them for doing their duty !

It is not intended in this paper to detail the treatment of drug-
takers. It is proposed only to discuss its relations to insanity,
to point out the warning there is to be read from ruined lives,
and to suggest some possible preventive action. Should not
something be done as a prohibitive or restrictive measure ? No
amount of therapeutics or legislation will make a bad man
good, a drunkard sober, or a inorphinomaniac abstemious ; but
legislation can limit opportunities to obtain drugs, and this was
the basis of the International Opium Conference in 1912. It
was to secure general agreement among the nations as to the
limitation of some of these dangerous drugs. It was felt that
it was not enough for a nation to protect its own subjects, but
each nation had a duty incumbent upon it to assist the efforts

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60 DRUG ADDICTION IN MENTAL DISORDER, [Jan.,

of others. It is reported that twelve Powers attached their
signatures to the first Convention, and at the second Opium
Convention, in 1913, the signatories of the Powers had increased
to twenty-two. In May of this year, no less than forty signa¬
tory Powers agreed that fresh legislation was needed; but the
cataclysm in Europe since that date, and the consequent and
inevitable reconstruction of the map of Europe, will possibly
render all the labours of the last Conference vain and devoid of
practical results, at any rate for some time to come. The
medical witnesses before the Parliamentary Committee on
Proprietary Medicines, of which Sir Henry Norman was chair¬
man, all demanded further restrictions in regard to the sale of
patent drugs, in order to prevent the indiscriminate use of those
drugs which are likely to endanger the health of the community,
and our own country is sadly lacking as to restrictions and
safeguards in regard to their sale. I have known cases of
insanity due to drink which have recovered in asylums to take
a vow upon their discharge that they would never again touch
it, remarking apologetically that they found it easy to pass one
public-house in the same street, but it was a sheer impossibility
to pass eighteen of them ! There is no doubt that “ the means
to do ill deeds makes ill deeds done,” as is seen in my cases
where doctors, druggists, and nurses become victims. In the
absence of special legislation restricting the sale of dangerous
drugs it would be wrong to punish the druggist for the lying,
deceitful, and often forged statements made by self-indulgent
drug-takers, who themselves escape punishment. In this
country the sale of a number of drugs, such as acetanilide,
antipyrin, phenacetin, male fern, and others, is absolutely
unfettered by any control, nor is their sale limited to the
chemist, who is trained to dispense medical remedies. The
law in this country, as has been pointed out in an able article
in the Lancet for December 14th, 1912, allows practically
untrammelled the sale of many very active therapeutic agents
which are a danger to the public, and it allows their sale with¬
out either the advice or the knowledge of the doctor. Such
freedom opens the door for license and the indiscriminate self¬
dosing, the victims of which often commence their downward
career in ignorance of the disastrous results.

In conclusion, it cannot be too seriously apprehended by,
nor too strongly impressed upon, medical men that they have a

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great responsibility in the matter of drug addiction. The care¬
less use of the hypodermic syringe, or the unconsidered fascina¬
tion of sedatives, has led to grievous results. Several of my
cases traced their downfall to the use of sedatives upon medical
advice. It should be more difficult for the rank and file to obtain
access to drugs and special stimulants, and this country is behind
others in this respect, and this matter is certainly deserving of
attention by the Council of this Society. I would go further,
if permitted, and state that no medical man should ever use the
hypodermic syringe for any patient suffering from neuralgia,
hysteria, or sciatica, and no medical man should lightly place
in the hands of patients the means of indulgence in any of the
drugs mentioned in the list appended without very serious con¬
sideration and reflection.

Inferences.

The conclusions to be drawn from my experience justify the
following statements, viz.:

(1) Drugs, and the habit of drug-taking, are a cause of insanity
and are a public danger.

(2) The symptoms are a serious injury to health, and a
deterioration of all the elements of the mind, but mainly of the
moral faculties.

(3) The victims are mostly among the cultured, the artistic,
and the best brain-workers of the community.

(4) Such a destruction of the ablest and best minds is pre¬
ventive.

(5) Restriction of the sale of dangerous drugs is urgently
needed in the public interest.

(6) The attention of the Privy Council should be called to
this pressing need.

( l ) Read before the Society for the Study of Inebriety, at 11, Chandos Street,
W., on October 13th, 1914—( s ) Article, “ Vice, Crime, and Insanity,” Clifford
Allbutt's System of Medicine.

Discussion.

Dr. W. H. B. Stoddart stated he was in much sympathy with the movement to
limit or check the drug-habit, as he knew how prevalent this was, more especially
among those who had an easy access to sedative poisons. He agreed that doctors,
nurses, chemists and druggists, and even dentists, were the most common victims,
and he felt how difficult it would be, even under the most prohibitive regulations,
to prevent this class from the indulgence, but he thought that such restrictions
would prevent others from becoming habitues. He did not agree that insanity
was a common result of indulgence in drugs, although it undoubtedly occurred, or
that drug-taking was a common result of insanity, although that also undoubtedly
occurred, but he conceived the relationship to be that both drug-taking and

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insanity were the result of a search by the unconscious mind for a refuge from
stress. He was at the present moment undertaking the effort of rescuing one
person, apparently in perfect health, who had been taking cocaine for twenty-three
years, and he felt that there must be to victims a relief from stress in the drug-
habit, therefore the question arose whether, to the psychopath and the neuropath,
such an indulgence, if limited to a therapeutic dose, might not actually stave off an
attack of insanity? This is a matter which was worth raising in a discussion such
as the present opportunity afforded. His experience of cases of drug-taking was
limited to only about two cases in each year, but he quite agreed that there were
numerous victims of the drug-habit who never consulted a doctor for it. He
considered that Dr. Armstrong-Jones’ record of forty cases, the result of a long
and large experience, proved that the excessive use of drugs was a danger, and
he, himself, was sympathetic towards any measure which would tend to diminish
and control such indulgence.

Dr. W. H. VVillcox said that the sale of poisons in this country was too
little under control and far too unrestricted, and he called attention to the
difficulty, owing to trade interests and other causes, there was in obtaining the
scheduling of dangerous remedies. He, himself, knew of many cases in which
suicide had occurred through the too easy way in which dangerous drugs like
veronal could be purchased, and he stated that statistics as to suicides were,
naturally, unreliable. He considered that the easy access to dangerous drugs
was a public evil. An important step was the scheduling of veronal and of all
its derivatives, such as the compounds of barbituric acid, medinal, luminal,
proponal, and also all poisonous ureides, but he agreed that application should be
made to the Privy Council to schedule other poisons such as had been suggested
by Dr. Armstrong-Jones, and antifebrin or acetanilide was certainly one which
ought not to be sold as at present. He was strongly of the opinion that the
supply of dangerous drugs should only be through medical prescriptions, and this
should only be possible once. All doctors knew how prescriptions containing
dangerous remedies were presented again and again without the doctor’s sanction,
and not only was this done, but it was used by other persons for whom the drug
had never been prescribed. He considered it would be for the public welfare if all
hypnotic and narcotic preparations intended for use by the hypodermic syringe
should be sold only by a doctor’s prescription, and a prescription should only be
presented and used once, unless it is fully signed by a qualified medical man at
each repetition. There was a large number of very dangerous drugs which were
not yet scheduled, and he considered, in spite of the many trade interests, that
their use should be limited, and that this Society should initiate measures and use its
influence to obtain restrictions and prohibitions in the case of the sale of dangerous
drugs.

Dr. J. Milne Bkamwell had carefully studied this question of drug-taking, and
had a large experience in its treatment. He had spoken and written upon the
subject, and he agreed fully with the remarks of Dr. Henslowe Wellington that
dangerous drugs should only be used in medical prescriptions, and that these
should not be passed about or presented without the doctor’s consent. He knew
of many cases of light insomnia, of headaches, or of neuralgic pains which had
been relieved by sedative remedies, the abuse of which had caused the ruin of
many a promising career. He expressed his full concurrence with the object of
the paper, and had attended the meeting to record his own strong protest against
a too easy access to narcotic drugs. He thought the opinions expressed were
those of different standpoints, and were very representative of professional
views, and he hoped the meeting would greatly strengthen the hands of those
who desired restrictions.

Mrs. Scharueb (the President) quoted her own experience of a gifted, bright,
and high spirited lady-medical student, who started upon the morphia habit light-
heartedly, but ended by becoming its miserable slave. No appeal to her honour,
and no warning as to her future were of any avail. She sank lower and lower in
the social scale, until degradation, poverty, and self-abandonment had completed
the ruin of an otherwise brilliant future. The paper read by Dr. Armstrong-Jones
made a great impression upon her because it recalled to her one who had been
one of the most promising of medical students, and her own experience could be
supported by those of others, not only in the medical, but in other professions. It

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was a sad warning that the drug habit appealed mostly to the brain-worker, and it
secured its victims from the most interesting, because the most artistic, and,
often, the most gifted and cultured. She could state, as President of the Society,
that the matter of restriction would be made the subject of special attention by
the Council of the Society for the study of inebriety.

Dr. Edwin Ash said he was quite in sympathy with the conclusions which
Dr. Armstrong-Jones had advanced in his paper. The whole matter resolved
itself into how far it would be possible to prevent morbid drug-taking. He divided
drug-takers into three classes, via., those who were only beginning the drug-habit,
who took drugs occasionally to relieve pain, or to obtain mental relief from tem¬
porary distress or trouble, and who might be described as occasional drug-takers ;
those, secondly, who had come under the sway and influence of the drug, but
whose work was done more or less satisfactorily, with only temporary remissions
of failure—and those he classified as the cravers; lastly, there were the actually
broken-down drug -habituts who had become mental and physical wrecks. The
three groups were not actually separate, but were, broadly, those into which drug-
takers could be classified, although recruits from each lighter class tended to join
the wrecks, and those who were completely broken-down. He thought the chief
hope of stopping the gradual deterioration of the early drug-taker was through the
persuasion and the warning of the general practitioner, who might be able to stop
a victim in the beginning of the habit. He agreed that the pyschasthenic or the
neurasthenic were peculiarly susceptible persons, as they felt the sedative effect of
drugs to be a temporary help when suffering from restlessness, irritability, neu¬
ralgia, and headaches; also that these persons were the most active and the least
stable, and they suffered from all the common early disturbances which sedatives
relieved for the time being. Dr. Ash considered that a more systematic attention to
the early signs of functional nervous disorders would be a controlling factor in the
drug-taking habit. He hoped the Society would approach the Privy Council
upon the matter, as he felt certain that in regard to restrictive legislation this
country was behind other European countries in the direct control of poisons, and
certainly so far as facilities for the public to purchase them was concerned.

Dr. R. Henslowe Wellington said he spoke as the Deputy-Coroner for
Westminster, and as possessing both a medical and a legal training. He knew as
a writer—for he had contributed the article, “ Law and Medicine,” to Lord
Halsbury's Encyclopaedia —the difficulty there was in getting drugs classified in the
schedule, for it must be quite possible to differentiate cause and effect, and he
agreed that in some cases it was difficult to say whether the drug-habit had caused
insanity or the mental disturbance had initiated the habit, but of this he was
certain, that dangerous drugs ought to be under far greater restrictions than they
were at present in this country. He knew how insidious and progressive the self¬
using of sedatives was, and how, in the case of alcohol, curiosity was not infre¬
quently the exciting factor in a downward career of drunkenness. He felt very
strongly that remedies such as had been the cause of insanity in so many of the
cases recorded by Dr. Armstrong-Jones should only be used, and only obtainable
in a medical prescription, and that each prescription before it was possible to
present it again should receive the signature of the doctor. He, himself, was
strongly against powerful remedies being used in prescriptions, and he felt there
was insufficient control of such remedies even by doctors. He referred to the
opium-habit formerly common in the fen districts of Lincolnshire, but with
improved drainage and sanitation the use of opium was unnecessary, as ague itself
was now uncommon. He thought, with a due understanding of cause and effect,
fewer of the strong poisons would need to be used, but he felt, strongly, something
should be done by this Society to control the sale of dangerous drugs, and he
would like to see a joint committee of this Society and the Medico-legal taking
the matter up, and making it the subject of a full inquiry with a view of obtaining
a more definite control as to the sale of poisons.

Dr. Wynn Westcott said : I have considered the question as a Coroner, and
say that the people in my district of North London are too poor or too hard-
worked to buy morphine, sulphonal, etc., but I have had the deaths of three doctors
within my experience, one from opium-taking, and one from morphine injections
—these used often to come to inquests "half insensible”—and a third from
addiction to tincture of nux vomica, of which he used to take a dose every morning.

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I regret to say that since the war began the deaths I have investigated as a coroner
have doubled in number—women and men—from delirium tremens and alcoholic
excess, and I hear from the police at Bethnal Green that women are drinking
much more, especially in the mornings. Many money-earning wives and women
have more money now than when their soldier husbands were at home, for they
used to take part of the women’s earnings.

Sir Gkorge H. Savage said: In England one sees chiefly those who have
established a morphia or cocaine habit. In some cases doctors have been the
cause of the taking of the drug, but I regret to say that, as opportunity leads to
faults, so the ease with which doctor and druggist can get the drugs lead to the
numbers of members of these callings taking to the habit. As a rule, the drug-
taker loses all moral sense. He has no regard for truth or honesty, and will lie
even when “ on his honour,” and to any extent. He is, possibly, curable, but I
generally say that any young man or middle-aged one who has taken to morphia,
and having been cured once falls again, is never to be trusted. I have seen some
cases in which marked mental weakness, the so-called “facility,” has followed
prolonged drug-taking. Cocaine is, to my mind, in every way a more dangerous
drug; it is taken so often with the idea of breaking the morphia habit, or to
check the craving. The symptoms often arise so slowly and insidiously that for
a long time they are only considered as developments of the normal temperament
of a suspicious man. I have seen the slow passage from doubt to suspicion, and
then to fully-developed delusions of persecution. Other drugs, such as chloral
and the various chemical sedatives, may give rise to various nervous symptoms,
but I do not think they are specially noteworthy as causes of insanity. I have
known paraldehyde produce active delirious insanity resembling delirium tremens.
I trust the Mental Deficiency Act will enable us to control drinkers and drug-
takers, and will protect the doctors who arc bold enough to make use of the Act.

Friedrich Nietzsche. By Hubert J. Norman, M.B., Ch.B.,
D.P.H.Edin., Assistant Medical Officer, Camberwell House,
S-E.(')

Part /.—Parentage and History.

Friedrich Wilhelm Nietzsche was born at Rocken, in
Saxony, in 1844. His father was a Lutheran clergyman, and
his grandfather held a high official position in the Lutheran
Church. His grandmother Nietzsche “ came of a family of
pastors,” and his mother was the “daughter of a parson ”(1).
In view of the strongly antagonistic attitude which Nietzsche
afterwards adopted towards the Christian scheme of morality,
the marked clerical strain in his ancestry is worthy of note.
According to his sister their ancestors, paternal and maternal,
were very long-lived (2). “ Of the four pairs of great-grand¬

parents [one] great-grandfather . . . reached the age of ninety,
five great-grandmothers and great-grandfathers died between
seventy-five and eighty-six, two only failed to reach old age.
The two grandfathers attained their seventieth year, the maternal

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grandmother died at eighty-two, and grandmother Nietzsche
at seventy-seven.” Nietzsche’s mother was also long-lived ;
she was born in 1826, and was married, in 1843, to Pastor
Nietzsche, who was then thirty years old. She died in 1897,
"after having suffered ill-health for several years ” (3). Pastor
Nietzsche is described by his daughter as being an “extra¬
ordinarily sensitive man . . . any sign of discord, either in the
parish or in his own family, was so painful to him that he
would withdraw to his study, and refuse to eat or drink, or
speak with anybody ”(4). This tendency to seek solitude is
worthy of note, as it reappeared in a very marked degree in his
son, Friedrich. The father was short-sighted—as was Nietz.che
—and, in 1848, this resulted in an accident, the consequences
of which were disastrous : he tripped over an obstacle which his
defective eyesight had prevented him from observing, and he
suffered as a result from concussion of the brain. This shock to the
nervous system initiated a train of symptoms—chiefly cerebral
—which led to his death eleven months later. The fall may
have been the cause of the attack ; or, as another biographer
says, perhaps “ only hastened its approach.” The same writer
informs us that Pastor Nietzsche “ might have hoped for a
fine career had he not suffered from headaches and nerves” (5).
Frau Forster-Nietzsche, however, says (6) that her father had
not suffered from headaches prior to the accident. In view of
Nietzsche’s history, one feels inclined to agree with Halevy,
more especially as, where any history of nervous or of mental
symptoms of a morbid character are concerned, relatives are
usually the last to admit them. Miigge says that Pastor
Nietzsche “ suffered either from concussion or softening of the
brain . . . doubtless this accident hastened his death” (7).
The youngest of the three children born to Nietzsche’s parents,
a boy, died just after his second birthday “ from teething con¬
vulsions ” (8). There was apparently nervous instability in
the family ; and Ireland says that O. Hansson “ learned from
a family who knew Friedrich Nietzsche from childhood that a
disposition to insanity had been inherited for several genera¬
tions, both on the father’s and the mother’s side ”(9). This
statement is not in accord with the details of family history as
given by Frau P'orster-Nietzsche; at the same time, it is,
perhaps, no injustice to her to surmise that she was desirous of
minimising the pathological aspect of the family heredity, and
lxi. 5

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[Jan.,

of laying greater stress upon the more favourable characteristics.
When Nietzsche’s life-history with its morbid mental vicissitudes
is considered, however, it would be surprising if the family
annals were found to be clear of all traces of nervous instability.

As a child, there is little that is abnormal recorded of him.
He was late in learning to speak ; he was two and a half years
old, his sister informs us, before he began to talk. As a
school-boy, he kept a good deal apart from his companions, and
he was even at this time inclined to be solitary and intro¬
spective. By the time he was ten years old, he had made
considerable advances in regard to his school-work, and he was
able “ to compose motets and write verses and plays.”

In 1857, for the first time, according to his sister, Nietzsche
began to show signs of eye-trouble, and he suffered from head¬
aches which may have been due to this. It was noticed also
that his pupils were at times unequal (10). About five years
later there was some mental change which his sister finds diffi¬
cult to explain ; the “ exemplary boy ” became a “ somewhat
slack scholar,” and he began to feel an “ extraordinary dissatis¬
faction with his surroundings.” This was associated with
physical disorders; “healthy and strong as he looked, he
suffered a good deal during this time from colds, hoarseness,
and repeated attacks of eye-trouble and headaches” (11).

In 1864, Nietzsche went to Bonn University ; in the follow¬
ing year, he left there, disgusted with the “coarse, Philistine
spirit, reared in this excess of drinking, of rowdyism, and
running into debt.” He went next to the University of
Leipzig, where he remained until 1867. After leaving there
he began his military training, but as a result of an accident to
his chest he was invalided at the expiration of five months.
In 1869, he went to B&le as Professor of Classical Philology;
in 1870, war having been declared between Germany and
France, he set out for the front as an ambulance attendant.
He contracted dysentery and diphtheria, whilst attending upon
the wounded ; he had to relinquish his duties on the field, and
he returned to his work, at B&le, in the same year. In January,
1871, “he got jaundice, inflammation of the bowels followed,
and in addition to this he was terribly tormented by insom¬
nia ”(12). It was in this year that his first book, the Birth of
Tragedy , was published. In the early part of 1872, he was
again in good health ; towards the end of that year he com-

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plained ofheadaches and disturbed sleep. In 1873, he became
worse ; “ his short-sightedness considerably increased in the
spring, and was accompanied by pains in the eyes and in the
head” (13). Later in the year, however, his health improved,
and he became cheerful; but in the early part of 1874, he
became again “ depressed in spirits.” He had projected great
plans for the future, but he felt that he was unable to carry
them out. “ If only you knew,” he wrote to a friend, “ how
despondent and how melancholy I feel about myself as a pro¬
ductive creature. . . . For the moment I am really very,

very tired of everything—more than tired.” He adds—and this
is significant—“ my health is excellent.” Shortly afterwards,
according to his sister, “he recovered his pride and good spirits.”
In the winter of 1875, “another spell of indisposition super¬
vened, and for some months he remained ill and depressed ” ;
then “ in a few days . . . his buoyant nature quickly

recuperated” (14). Again he became “cheerful and in high
spirits, but by the following spring he was depressed, and
during this time he “ took an extraordinary quantity of medi¬
cine.” During the period from the middle of August to the end
of November, his “ health was really excellent. From early in
the morning till late in the evening he was radiant and cheerful,
and declared himself exceptionally pleased with every¬
thing” (15). Just previously to this, Nietzsche had written to
a friend that his trouble had been diagnosed as “ chronic
gastric catarrh, accompanied by great dilatation of the stomach.
This dilatation causes vascular engorgements and results in the
brain being insufficiently supplied with blood,” and he added,
“ I am to take Carlsbad salts, and am to have leeches applied
to the head.”

From the end of November, “ his good health gradually
declined he went out of doors seldom, and “ even lost all
taste for long excursions.” He again had recourse to drugs.
“ After Christmas his steadily declining health broke down
altogether. He suffered from terrible headaches and violent
nausea.” Gradually his health began to improve, and of the
early period of 1876 his sister writes: “I was somewhat
surprised to see my brother in such good spirits during the
spring of this year” (16). She wondered the more as she
knew that her brother’s offer of marriage had just been refused
by a “charming girl.” Indeed, it is rather pathetic to observe

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throughout Frau Forster-Nietzsche’s account of her brother’s
life how she strives to formulate reasons for his varying mental
phases, and the bewilderment in which she—and, it may be
added, the doctors also—found themselves at the apparently
inexplicable nature of his trouble.

Another observer thus describes his appearance during this
period : “ Nothing was more deceiving than the apparent calm
of his expression. The fixed glance betrayed the melancholy
labour of his thought. It was the glance of a fanatic, of a
keen observer, and of a visionary ” (i7). It was about this
time that he was writing the first part of Human , All Too
Human : and Hal^vy’s significant comment in regard to it is
that in it the author “ reverses every thesis that he has hitherto
upheld ” (18). When September, 1878, was reached, “hewas
leading a painful and miserable life ... he was avoided,
for his agitated condition gave alarm ” (19). The second part
of Human, All Too Human appeared in 1879 ; his health grew
worse—“ the doctors began to be disquieted by symptoms
which they could not ascertain, by an invalid they could not
cure. It appeared to them that his eyesight, and perhaps his
reason, were threatened ” (20). He shut himself up in his
room “ behind closed shutters and drawn curtains.” A friend
wrote of him at this time, “ His condition is desperate.” When
his sister saw him after a short absence, she “ scarcely recog¬
nised the stooping, devastated man, aged in one year by ten
years.” He thought that he was lost, that he was going to
die ; he made arrangements for his obsequies ; he longed for
solitude. He gave up his professorship at Bale. Toward the
end of this year, however, he was able to write : “ It seems to
me that I feel gayer, more kindly than ever I was.” But in
December he says : “ My condition has again become terrible,
my tortures are atrocious.” By the middle of February he was
again cheerful, he felt a “ reawakening of his strength.” He
continued in this improved state until 1881, in which year
The Dawn of Day was published : a book which he regarded
as the “ exercise of a convalescent who amuses himself with
desires and ideas ”(21). He went to lead a retired life in the
Fngadine, and he is reported to have been “ for some weeks in
a condition of rapture and of anguish. . . . He expe¬
rienced a divine pride . . . His agitation . . . became
extreme ” (22). He realised to some extent his own condition,

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for he wrote : “ Presentiments cross my mind. It seems to me
that I am leading a very dangerous life, for my machine is one
of those which may go smash ! The intensity of my senti¬
ments makes me shudder, and though twice already I have had
to stay in my room, and for a ridiculous reason ; my eyes were
inflamed, why ? Because while I walked I had cried too much ;
not sentimental tears, but tears of joy ; and I sang and said
idiotic things, being full of a new idea which I must proffer to
men.” Such was the state of mind in which he conceived
that strange and dithyrambic philosophical mystagogue, Zara-
thustra. There was, however, another halt, another period of
depression, before he could carry on his work. “ He lost his
exaltation . . . thrice, during these weeks of September

and October, he was tempted to suicide” (23). Towards the
end of December he passed a crisis, and surmounted it. He
became cheerful once more ; “ his gaiety amazed ” his mother
and sister, with whom he went to stay. Another book, The
Joyful Wisdom , was written during this period. Later in the
year (1882) we find him depressed again ; he became “ melan¬
choly and suspicious. One day he imagined that his com¬
panions, talking together under their breath, were laughing at
him ” (24). He broke with his friends ; he thought that
everyone had betrayed him ; he wished once more for solitude.
“ Perhaps he also wished,” says Haldvy, “ to put to profit that
condition of paroxysm, and the lyrical sursum whither his
despair had carried him ”(25). He set about his task of
writing Thus Spake Zaraihustra. It is a strange, fantastic
book, and Nietzsche’s mental condition at this time is reflected
in it. “ Every morning, on awakening from a sleep which
chloral had rendered sweet, he rediscovered life with frightful
bitterness. Conquered by melancholy and rancour, he wrote
pages which he had at once to re-read attentively, to correct or
erase. He dreaded these bad hours in which anger, seizing
him like a vertigo, obscured his best thoughts ” (26). There
are probably many who read Zarathustra who express doubts
as to Nietzsche’s having spent much of his time in revising
and correcting it.

During the year 1882 he wandered from one place to
another—Monaco, Rome, Grunewald, Leipzig, Genoa. Early
in 1883 he was in Genoa, thinking of retiring to his solitude
once more, but “ he is feeble, solitude exalts and frightens

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him.” So he went to Rome. But there he felt “discouraged
and ceased to write ”(27). Depression once more set in, and
he decided to flee from society. There was, however, a remis¬
sion which apparently lasted but a short time. His sister was
amazed at the sudden change ; during their journey back to
Germany “ he improvised epigrams, bouts-rimts ... he
laughed like a child, and in fear of troublesome people who
would have disturbed his delight, he called and tipped the
guard at every station ” (28). He returned to the Engadine,
to solitude, and to the writing of the second part of his Zara-
thustra. “In it we see no longer the hero whom Friedrich
Nietzsche had created so superior to all humanity ; it is a man
in despair, it is Nietzsche, in short, too weak to express any¬
thing beyond his anger and his plaints. . . . He is the

prey of a bitter and violent mood, and the virtue which he
exalts is naked force undisguised, that savage ardour which
moral prescriptions have always wished to attenuate, vary, or
overcome ” (29). He wrote long letters, which betrayed his
agitation, and which gave rise to anxiety in his friends. He
left the Engadine, and went to the home of his family in Naum-
burg. There he found a general atmosphere of domestic
quarrels, and he speedily departed for Genoa. From there he
wrote to a friend : “ Things go very badly. ... I can
live only at the sea-side. Every other climate depresses me,
destroys my nerves and eyes, makes me melancholy, puts me
into a black humour—that awful tare.” He moved on to
Nice ; towards the end of 1883, he was almost in despair, and
the beginning of 1884 found him still dull and capable of no
sustained effort. In January, however, the clouds lifted for
awhile, and he completed the third part of Zarnthustra .
Halevy describes it as a “ disorder of complaints, appeals, and
moral fragments which seem to be the debris left over from the
ruin of his great work ” (30). He left Nice and went to Venice
in April. The feeling of elation lasted apparently for some
months, and he was able to complete the fourth part of Zara-
thustra. At this time he had no doubts as to his great capa¬
bilities, and this exalted mental phase is obvious in a letter
which he wrote in March of this year : “ I do not hesitate to
avow that, in my opinion I have, with this Zarathustra,
brought the German language to perfection. After Luther and
Goethe a third step remained to be taken—and consider . . .

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7 I

were ever strength, subtlety, and beauty of sound so linked in
our language? My style is a dance; I trifle with symmetries
of all sorts, and I play on these symmetries even in my
selection of vowels” (31).

When September came, he was again depressed : “ very low
in himself, and at the same time exceedingly talkative. This
excited speech troubled [the friend who was visiting him].
... He spoke in a low and trembling voice, and his face was
troubled ” (32). This was in Bale ; he left for Zurich. There
he became again unduly elated. We are told that the hotel
in which he stayed “ resounded with his childish laughter.”

He went to Mentone still in a cheerful, elated mood ; and
whilst there he wrote much poetry—“ songs, short stanzas, epi¬
grams.” His restlessness hastened him off to Nice. The
feeling of elation passed, as a letter he wrote to his sister
proves: “ Here I am ill again ; I have recourse to the old
means [chloral], and I utterly hate all men, myself included,
whom I have known. I sleep well, but on awaking, I ex¬
perience misanthropy and rancour.” Haldvy tells us that his
behaviour was peculiar ; when out walking, for instance, “ he
would leap and gambol at times, and then suddenly interrupt
his capers to write down a few words with a pencil ”(33). In
April and May, he was in Venice, enjoying a “ short-lived
happiness”; in June, he returned to the Engadine. Thereafter
this truly peripatetic philosopher visited Leipzig, Naumburg,
Munich, Tuscany ; then he returned to Nice. By the end of
the year, he was again passing into a depressed phase. He
loathed the pension in which he was living : he objected to the
rooms, the furniture, the neighbours. “ Here is Christmas
again,” he wrote, “ and it is sad to think that I must continue
to live, as I have done for seven years, a man proscribed, like
a cynical contemner of men ” ; and, again, that he has had
“ nights and days that were most melancholy.” The next
year commenced more auspiciously ; during the first three
months, “ his melancholy appeared to be less acute.” He
wrote Beyond Good and Evil , which was published in the same
year. In the spring he went to Venice ; depression came
upon him once more. He shut himself up and remained
solitary. Quite suddenly, he felt that he must set off on his
travels once more. He went to Leipzig. An old friend whom
he visited there thus described the change which he observed

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in him : “All his person was marked with an indescribable
strangeness, and it disquieted me. There was about him some¬
thing that I had never known, of the Nietzsche whom I had
known many features were effaced. He seemed to have come
from an uninhabited land.” In July, he was back in the
Engadine ; and he felt the first symptoms of a “ long crisis of
neuralgia and melancholy.” His letters at this period are
marked by such expressions as that he is a “ stranger,” or “ pro¬
scribed man,” one “ with neither God nor friend.” This was
his state while he endeavoured to progress with the Will lo
Power , a book in which he was going to attempt to “ trans¬
value all values.” But first he must move on once more ; he
returned to the Genoese coast. He became more cheerful ;
Hal^vy suggests that he was now taking drugs to excite him
to work : “ We know that he was absorbing chloral and an
extract of Indian hemp, which, in small doses, produced an
inward calm; in large doses, excitement ” (34). During the
winter, 1886-87, “he lived ... in a singular condition of
relaxation, indecision, and melancholy.” He was by this time
back again in Nice; then to San Remo and Monte Carlo;
and once more to Nice. In the spring-time of 1887, he went
to Lake Maggiore ; and as the spring passed the depression
left him to some extent, and he was able to work more steadily.
The improvement lasted but a short time, and he departed to
Switzerland for a course of waters, massage, and baths. There¬
after he wrote, in the course of fifteen days, his Genealogy
of Morals. The following summer was spent in “ discom¬
fort and melancholy.” I11 the autumn, he was again in
Venice ; October in Nice. Towards the end of the year he
wrote : “Almost all that I have written should be erased.
During these latter years the vehemence of my internal agita¬
tions has been terrible.” Another year commenced, and found
him “again a prey to sadness. He complained of his sensi¬
bility, of his irritability.” In his own words : “Never has life
appeared so difficult to me. I can no longer keep on terms
with any sort of reality. . . . There are nights when I am
overwhelmed with distress” (35). He became worse : “suffer¬
ing and irritation deformed his memories.” He described his
state thus : “ Night and day, I am in a state of unbearable
tension and oppression ... my health . . . has remained
sufficiently good . . . nothing is sick but the poor soul ”(36).

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The end was approaching—at least in so far as his intelli¬
gence was concerned. The anabolic process had for years
been proving insufficient to keep pace with katabolism : the
tension in the nervous system had almost reached breaking-
point. Yet there was still to be a shower of sparks before the
end came ; and a singularly vivid display it was. His icono-
clasm became even more marked. One idol he attacked with
all the fury of diminishing control—Richard Wagner, his erst¬
while bosom friend—and him he calls a modern Cagliostro, a
low comedian, a decadent. He was still able to realise the
change in his condition to a great extent, however, though this
realisation did not prevent him from his onslaughts, his vitu¬
perations, his “philosophising with a hammer.” In a letter to
a friend, written in February, 1888, he said : “ I am in a state
of chronic irritability which allows me, in my better moments,
a sort of revenge, not the finest sort—it takes the form of an
excess of hardness.” In April, Nietzsche was in Turin, and
experiencing a period of excitement, during which he hurried
on his work. “ My humour is good, I work from morning to
night ... I digest like a demi-god, I sleep in spite of
the nocturnal noises of carriages.” When July came he was in
the Engadine—once more depressed. “ He lost his sleep.
His happy excitement disappeared, or transformed itself into
bitter and febrile humours. . . . He walked alone” (37).

He finished the Case of Wagner, and commenced a new essay,
which was completed by September, and was published later
under the title of The Twilight of the Idols . During Septem¬
ber another pamphlet was completed, and the title he gave to
this was The Antichrist. In it he exalts force—implacable,
pitiless, unrelenting—as the only thing of value : “ not peace
at any price, but war.” It is almost his last amazing paradox :
this worn and broken man uttering a paean to power. The
title is suggestive: Nietzsche may, indeed, have considered
himself as Antichrist. It is an indictment of Christianity : one
of his many fulminations against Christian ethics. Before the
year was out he wrote his Ecce Homo , and again, perchance it
was himself to whom he pointed therein as another Christ, for,
when the new year dawned, and the final collapse came, he
wrote as signature to one of his letters “ The Crucified.”

In the autumn of 1888, “his letters expressed an unheard
of happiness . . . He digests well, sleeps marvellously.”

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For this unfortunate man, with his nervous system on the
verge of utter breakdown, everything is for the best in the
best of all possible worlds, or at least in that part of it, Turin,
where he was then residing. The exalted mood continued
while he wrote his Ecce Homo. The titles of the chapters
are significant: “ Why I write such excellent Books ”—“ Why
I am so wise”—“Why I am so clever”—“Why I am a
Fatality.”

“ On one of the first days of January, 1889, near his lodgings
in Turin,” writes Miigge, “ Nietzsche had an apoplectic fit.
For two days he lay stupefied and unconscious on his sofa.
Later he was once more able to walk, but he had no idea of
the value of money, and paid for trifles with gold ; he spoke
loudly and constantly, and wrote many odd and quaint letters ”
(38). One of the letters he wrote about this time included
such passages as : “ I am Ferdinand de Lesseps, I am Prado,
I am Chambige [the two assassins with whom the Paris news¬
papers were then occupied]; I have been buried twice this
autumn.” A friend who hastened to him found Nietzsche
“ ploughing the piano with his elbow, singing and crying his
Dionysian glory ”(39). The same friend thus further describes
his state: “ He saw me, and, recognising who I was, rushed to
me, and embraced me passionately ; then, bursting into a flood
of tears, he sank back upon the sofa in convulsions. .
Nietzsche had hardly sunk back again, groaning and starting
convulsively, when they gave him a cordial to swallow. For
the moment calmness ensued, and Nietzsche began to talk
laughingly of the great reception which was prepared for the
evening. Therewith he was back in the sphere of illusions,
which he never again left while I was present—quite clear as
to my identity and that of others generally, but as to his own
involved in utter night.” Later, he saw him, “ his face like a
mask, and with hurried but unsteady gait,” being conducted to
the train which was to take him to an institution in Bale. He
was removed to another institution in Jena later in the month,
and in March, 1890, his condition having improved, his mother
took him to her home in Naumburg. The improvement was
only a limited one; his mental condition steadily deteriorated.
“ In 1895 he was suffering from a paralytic affection of the
jaw.” His memory was practically a blank. “ In the summer
of 1898 another slight apoplectic fit occurred, and the next year

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a more severe one. Nietzsche became weaker and more silent.”
He died of pneumonia, in August, 1900.

Part II.—An Attempt at Interpretation,

It is the fate of most—if not, indeed, all—writers and
teachers to be misunderstood. Hence the plague of exegetical
writings, and the obscurity or ambiguity of a writer may almost
be judged by the mass of commentary which he has given rise
to. The utterances of the Pythoness have not been unparalleled
in regard to the difficulty of their interpretation, nor are the
sayings of the prophets alone worthy of the application to
them of the terms “ ambiguous,” “ obscure,” or “ unintelli¬
gible”

It is not, however, always the fault of the author that his
sayings are misinterpreted. Each one of us imparts to his
rendering of the meaning of a particular passage something of
his own personality, or, as the phrase goes, we “ read into ”
the author something of our own view of the matters with
which he deals. That this bias is largely subconscious does
not make it any the less real, nor does it detract from the
influence it has upon our interpretation. This instinctive
feeling is so pronounced in some individuals that they are
rendered incapable of giving even the semblance of fairness to
their commentaries.

It is the subconscious bias, this instinct, which makes possible
the formation of sects, which gives rise to political parties,
which fashions men into enthusiastic disciples or into fanatical
opponents. It may spring from superficial knowledge—which
is but a higher and more dangerous degree of ignorance—or it
may be associated with a memory well stored with undigested
information. In any case, it is a prime necessity for anyone
who wishes to have—or who has without caring whether he has
or not—a large and enthusiastic band of followers. It is not
characterised by a conflict of motives, therefore the more
directly will anyone who is in this particular mental state
tend to make for his objective, undeterred by contending
impulses.

This state of mind comes into being most readily during
periods of national crisis, that is to say, when some predominant
emotional stress exerts its influence. This has been exempli-

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fied on a large scale in the crusades, in the dancing manias of
mediaeval times, in the witchcraft delusions, and during
hostilities between nations ; this feeling rises to a pitch when
reason is frequently quite overwhelmed—even to madness in
some instances.

That such a bias is, even in these enlightened days, not
quite unknown, a brief study of Nietzsche’s works, of those
of his biographers, or of articles regarding him which appear in
the press, will speedily convince us. It is a difficult matter to
come to a decision in regard to Nietzsche’s teaching even with
a great number of the facts before us, and there seems to be
only one way in which to reconcile the apparently contradictory
attitudes which are found when we study his life and his
writings. The contradiction was noted by his sister, who was
also his biographer, Frau Forster-Nietzsche, who says : “ It is a
problem that Friedrich Nietzsche, who denied our present
moral values, or at least traced them to sources absolutely
unsuspected hitherto—this transvaluer of values—should him¬
self have fulfilled all the loftiest and most subtle demands
made by the morality now preached among us. And he did
not do this because of any moral imperative, but from a
perfectly cheerful inability to act otherwise. I leave it to
others to solve this problem ” (40). There we have a very
plain statement of the contradictions in Nietzsche’s mental
outlook. It is, after all, a not uncommon problem ; it narrows
itself down to the contradiction between precept and practice,
which is a matter of daily observation. It looms more largely
in Nietzsche’s case because ofhis undoubtedly high intellectual
attainments, and also because of his indubitable sincerity. No
one who conscientiously studies Nietzsche’s life and works can
have any doubts on these points. He was no philosophical
charlatan, eagerly seeking after public applause or financial
gain ; he sought truth in season and out of season, even though
the publication of his beliefs cost him friends, money, and
public esteem, and even though he realised that his unflinching
attitude alienated him from his countrymen, and earned him the
title of “ un-German ” {Ecce Howo,p. 69). As Lichtenbcrger
says, “ His only passion was the search for truth.” Now,
whence came this immutable purpose, and in what did the con¬
tradictory elements take their rise ? No satisfactory answer
can be given to the problem of Nietzsche’s life and opinions,

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and the real contradiction between them, if these matters are
to be kept rigidly separated. It was because Nietzsche was so
greatly influenced by the fluctuations of an unstable nervous
organisation that he thought and acted as he did. Indeed, it
is almost misleading to speak of anyone being influenced by
the condition of his nervous system ; what the nervous system
(the brain-cells and the nerves) is, that we are, and until this
is realised there is no hope for a rational psychology.

Nietzsche himself recognised this fatal error in metaphysics,
and in that which so frequently parades under the name of
psychology. “ Just exactly as the people separate the lightning
from the flash,” he says, “ and interpret the latter as a thing
done, as the working of a subject which is called lightning, so
also does the popular morality separate strength from the
expressing strength, as though behind the strong man there
existed some indifferent neutral substratum , which enjoyed a
caprice and option as to whether or not it should express
strength. But there is no such substratum, there is no ‘ being ’
behind doing, working, becoming; the ‘ doer ’ is a mere
appanage to the action. The action is everything ” ( Genealogy
of Morals, pp. 45—46). We are conditioned in regard to our
possibilities just as the pendulum is conditioned ; but our
oscillations have a wider range. Education is limited in its
potentiality : you cannot fashion an intellectual man out of an
imbecile, no matter how you may strive by education to do so.
The whole of psychology must be based upon physiology ;
otherwise it is less well-founded than the house built upon the
sands. It is still the fashion to carp at this view of the
matter, and to call it gross or base materialism, but it is almost
a certainty that those who cavil in this manner have not taken
the trouble to investigate closely the facts upon which this
theory is based.

Nietzsche recognised this essential study of the bodily pro¬
cesses as the basis of all rational psychology. “ Man did not
know himself physiologically throughout the ages his history
covers ; he does not even know himself now. The knowledge,
for instance, that a man has a nervous system (but no ‘ soul ’)
is still the privilege of the most educated people ”( Will to
Power, vol. i, p. 187). Frequently he returns to this aspect of
the matter, and many passages might be quoted to exemplify
his views as to what psychology really is ; and one of his direc-

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tions of attack upon the teachings of Christianity is along the
line of proving that “ by far the greatest portion of the psy¬
chical apparatus which Christianity has used is now classed
among the various forms of hysteria and epilepsy.”

If we apply these teachings of Nietzsche to himself we shall
be in a fair way towards understanding the extremities to which
he was carried. But here we meet with the conflicting testi¬
monies of those who have given us accounts of his life. Some
writers maintain that Nietzsche was not insane until the begin¬
ning of the final breakdown, that is to say, until the latter part
of 1888 ; for example, Miigge, who maintains (41) that “ with
the data that we have , however , we must come to the conclusion
that Nietzsche's mind was healthy until the end of 1888."
He admits (42), nevertheless, that “ it is at any rate possible
that Nietzsche was predisposed by heredity”; and he states
that “ perhaps the origin of his physical and mental ill-health
should be attributed to the accident which befel him during his
military service, or to the severe dysentery from which he
suffered during the Franco-German War.” (The accident to
which he refers was the injury to the chest already men¬
tioned). Miigge goes on to say that after the year 1881, after
which time his purely philosophical works were written,
“Nietzsche was comparatively well”; but he adds that “in
1882 he began to take hydrate of chloral,” and he admits this
“caused him to see men and things in a false light the next
morning ... he again and again struggled to give up the use
of that drug ” (43). He quotes Chamberlain as saying that the
first signs of the fearful malady appeared as early as 1878,
“ scattering the splendid intellect, and making him the court
fool of a frivolous, scandal-loving fin de siecle.” Halevy, deal¬
ing with the period of the onset of the final breakdown,
says (44) : “ Nietzsche’s thought has no longer a history, for an
influence, come not from the mind but from the body, has
affected it. People sometimes say that Nietzsche was mad
long before this. It may be that they are right; it is impossible
to reach an assured diagnosis.”

His sister, Frau Forster-Nietzsche, in dealing with the earlier
period of his life, remarks frequently, as we have shown, upon
the vicissitudes which he experienced mentally during that
time. She seeks to explain them by adducing various factors
such as the diseases which he contracted during the Franco-

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German War, the drugs which he took, and the dyspepsia which
resulted from their use (45). Again, she says : “We assumed
that the eye trouble (myopia) was the outcome of indetermin¬
able trouble elsewhere, whereas, now, we know that the former
was the chief agent in bringing about the general decline of
his health”; and, not content with this quite formidable assort¬
ment of causes, she involves emotional stresses. “ It should
not be forgotten that, with a nature as sensitive as my brother’s,
spiritual suffering, and such shocks as those which his changed
relations to his best friend (Wagner), and the alterations in his
convictions and ideals involved, proved much more painful and
difficult to endure than bodily indisposition ” (46).

Dr. G. M. Gould lays much stress upon the short-sightedness
from which Nietzsche suffered even as a child ; he maintains
that it was the prime cause of the headaches, and that most of
his other symptoms—cerebral, neural, digestive, etc.—were
secondary to this (47). Nordau’s essay on Nietzsche gives one
the impression of him as a madman with scarcely a lucid
interval ; and the shower of invective which he rains upon him
does more credit to his power as an anathematiser than to his
trustworthiness as a critic. The most biassed of Nietzsche’s
followers has not reached to such a degree of fervour of
admiration as Nordau has attained to in the way of condemna¬
tion (48).

It is, however, needless to multiply instances of the dis¬
crepancies which exist between the verdicts of the critics. The
most interesting point to be noted is the assured manner in
which those who have no practical experience in regard to
insanity undertake to deal with matters which, one would
imagine, require a certain amount of expert knowledge.
Everyone is, however, an amateur alienist, but when the
question is one of heart trouble or of renal disease, let us say,
it is approached with a due sense of the limitation of know¬
ledge on the part of the layman. It is even so when the con¬
ditions known as organic changes in the brain and nerves are
under discussion. If, however, those more delicately organised,
and less stable parts of the nervous system, the functionings of
which are called mental, are affected, then everyone may have
his say. No special study is requisite, we may infer, where the
most complex workings of the nervous system form the subject
of debate. This is, of course, a comparatively well-founded

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belief where it is a matter of dealing with mataphysical systems
involving discussions of the “ ego ”—that formless, disembodied,
elusive ghost. That it is still possible in regard to the dis¬
cussion of the physiological and pathological changes which
underlie—or which are named—mental processes is because the
study of these changes is practically still in its infancy. “The
study of the mind has passed,” says Professor Karl Pearson,
“ for good or bad, from the poetry of metaphysics to the
observation and experiment of the laboratory ” (49). This
was, as has already been noted, Nietzsche’s position, but it is
one in which he would be little likely to receive support from
his enthusiastic disciples. It would probably prove too
“materialistic” for them. Yet this is what he maintained.
“ All tables of value, all the * thou shalts ’ known to history
and ethnology, need primarily a physiological , at any rate in
preference to a psychological, elucidation and interpretation ;
all equally require a critique from medical science” (50).

It is this “critique from medical science” which is so
eminently necessary in the case of Nietzsche. To a certain
extent he was able to supply something of the kind himself,
but it must be obvious that such introspective analysis must
necessarily be limited. When the very part of the organism
which carries on this introspection is interfered with by drugs
or by disease, then its function must depart commensurately
with the extent and progress of the organic change. There
are variations in different individuals in their response to
morbid as to normal stimuli, yet these variations are not by any
means so great as to forbid classification. Thus anyone who
will trouble to study Nietzsche’s life-history, and then compare
it with the descriptions given by a famous countryman of
Nietzsche, Prof. Kraepelin, of Munich, or by other alienists, of
certain patients who have come under their care, the resem¬
blance will be found to be striking. In Kraepelin’s classifica¬
tion, these patients are designated as suffering from maniacal-
depressive insanity, that is to say, they alternate between
phases of intense abnormal mental excitement and equally
marked depression, without adequate external cause, and with,
in some instances, between these phases, intervals of apparently
normal health. During the excited phase there is an almost
feverish desire to compose, to criticise everything, to concoct
great schemes; the patient’s mood is “ arrogant, conceited,

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8 l

generally condescending, occasionally irritated or apprehen¬
sive.” He writes, but “ only produces fugitive, carelessly
jotted-down written work, with numerous marginal notes.
Physically, he is well.” In the particular case which Kraepelin
has been describing there was later a period of depression
“ with repeated and distressing changes of decision in matters
of importance, with incapacity for work, fluctuations of mood,
and hypochondriacal disorders” (51). This was apparently the
condition from which Nietzsche suffered, at least during the
productive years of his life. Here, again, we find the alter¬
nation between abnormal excitement and depression ; the
periods when he went breathlessly on writing, writing, writing,
with little apparent attempt to bring about cohesion between
one aphoristic utterance and the next ; when he left pity,
humility, charity, and all that he designated as the “ Christian ”
virtues, the ethical values which meant for him the “ slave ”
morality, faf behind him, or merely considered them as useful
in so far as they fashioned those in whom they were found
into a mediocre, “ slave ” community, upon whom the “ over¬
men ” or “ supermen ” might batten and flourish. At these
times, he is not found complaining of his bodily troubles, of his
aches and pains. Not that his health was necessarily robust
because he did not complain, but the mental state into which
he passed—the irritability of certain areas of his brain-tissue—
was too potent to allow even the stimuli from disordered organs
to dominate it.

Then there were the periods of depression, times when he
was obsessed by his physical ills—“ some,” as one of his bio¬
graphers says (52), “imaginary, no doubt, but others real
enough.” The same writer says of Nietzsche that, during the
year 1880, “ he became, indeed, a hypochondriac of the first
water, and began to take a melancholy pleasure in his infirmities.”
So marked was this depression at times that he was tempted to
commit suicide (53); at others he feared death because it
would cut him off before he was able to write down his
philosophy ; he shunned society, and “ longed for the most
desert and silent places, for the most complete solitude” (54).
He was a chronic drug-taker ; he absorbed large quantities of
medicines for his real and imaginary diseases, and, “ unable to
eat or sleep, he resorted to narcotics, and, according to his sister,
he continued their use throughout his life” (55).

LXI. 6

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In alternating states such as these, the “Transvaluer of
values,” the “ Prophet of the Superman,” passed the years of
his literary productiveness. In 1889, when the final break¬
down came, Nietzsche practically passed out of existence as
a sentient human being. He lingered on, a human derelict,
incapable of any intellectual effort, until 1900.

The presence of mental instability in certain of its forms
does not, it is true, preclude the sufferer from arguing rightly
and logically, but a knowledge of the existence of such a con¬
dition does not inspire us with confidence in the infallibility of
his reasoning. In a court of law the evidence of such a one
would be viewed with suspicion, and, in the event of his having
committed a crime, his responsibility for the act would be a
matter for debate. When Swedenborg tells us that Heaven and
Hell have been opened to him in visions, when Blake says that
he saw the Devil grinning at him in the stairway, or when
Cowper states that a voice told him that he was lost and
damned for ever, we do not believe straightway that such
things are so because we have their word for it. We do not
adopt this attitude because we doubt their honesty, but because
we are not convinced that they were in such a mental state
as to be able to discriminate accurately in these instances
between what was actually stimulating their sense-organs, and
might rightly be called vision or voice, and what, on the other
hand, was giving rise internally to such a commotion in the
nerve-cells as to convince them that they were actually in¬
fluenced from without, whereas, as a matter of fact, it w'as
certainly not so ; in other w'ords, they were subject to halluci¬
nations. Nietzsche himself said : “Fancy humanity having to
take the brain diseases of morbid cobweb-spinners seriously ! ”
(Twilight of the Idols , p. 20). At the same time, and in
regard to other matters upon which the mental disorder had
no bearing, most of those named were quite sane and reason¬
able, but their lives from the onset of the nervous derangement
were yet to some degree influenced by it—if we consider their
whole extent, and not isolated acts.

Within certain limits, then, we may agree with Mr. Mencken
when he says (56) that even “ if we admit the indisputable
fact that Nietzsche died a madman, and the equally indis¬
putable fact that his insanity was not sudden, but progressive,
we by no means read him out of court as a thinker. A man’s

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reasoning is to be judged, not by his physical condition, but by
its own ingenuity and accuracy. If a raving maniac says that
twice two make four, it is just as true as it would be if Pope
Pius X or any other undoubtedly sane man were to maintain
it.” The analogy is—as analogies so often are—misleading :
in' the instance given, the assertion is capable of proof, its
correctness is assumed because common experience has not
tended to disprove it. When anyone diverges from accepted
opinion in regard to certain matters, he is looked upon with
suspicion—which does not necessarily prove that he is wrong,
but that he is divergent ; but when Nietzsche asserts that all
the opinions commonly known as morality are wrong, many
people have a suspicion that what he is trying to prove is not
that two and two make four, but that, let us say, they make
five! Nor can Nietzsche nor anyone else who makes such a
sweeping assertion as that complain if all his credentials are
demanded of him before the truth of his statement is accepted.
If we grant his premises, we may accept his conclusions; but
then we may deny the premises—and this many have already
done. Again, we must be permitted to exercise discretion as
to how far we shall acquiesce in a lunatic’s doctrines, if we
shall be governed not only by a consideration of his physical
—and consequently of his mental—state, but also we shall
wish to know upon what data of experience his system is
based. We shall be chary of accepting the conclusions of the
tyro in economics, of the quack in medicine, of the amateur
alienist in regard to insanity, or of the armchair tactician in
matters of strategy, no matter how ardently they may assert
their infallibility; with Nietzsche we shall refuse to accept
“ passion as an argument for truth.”

If, however, we ask to be allowed to exercise discretion in
regard to what we shall accept as true, and what we shall reject
as false, or, at least, illogical, it should not be because we wish
to acknowledge only that result as truth which accords with
our own limited experience, or which flatters our prejudices.
We must remember, too, that in reading Nietzsche when we
feel inclined to utter stringent criticisms of a harsh phrase, that
perchance it was the utterance of a sick man, and that when he
gave vent to it he was looking out upon the world with a
jaundiced eye. It is as idle to dismiss Nietzsche as a foolish
babbler as it is to give him the position which he arrogated to

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himself during his exalted phases. His was a brain of remark¬
able power ; and the almost random and disconnected utter¬
ances which he was able to give forth make it all the more to
be lamented that the “ sacred fire ” did not burn more steadily
within him.

Possibly Nietzsche’s scheme of things will be judged quite
irrespective of his mental state when he evolved it; if so, con¬
siderable injustice will be done to him. The portrait which
anyone who is acquainted only with his writings will draw of
him is likely to bear little resemblance to the man who actually
produced them. Indeed, he himself shrank from even the
suggestion of the applicability of certain of his doctrines, as,
for example, those in regard to women. It was the appeal
from Nietzsche drunk to Nietzsche sober : from the utterer of
ferocious sayings under the influence of intense cerebral irrita¬
tion to the same being when the irritable phase had passed off.
It is to be regretted that the exalted, arrogant phases were so
predominant. In even the disconnected utterances which are
so characteristic, especially of his later writings, there is so
much that is valuable in the way of criticism of the general
placid acceptation of things simply because they are old or
customary, that one wishes he had been allowed to promulgate
some coherent system, or that he had been able to criticise his
own writings more calmly when the wild fit left him. He
would have realised that, for example, the accepted scheme of
morality is a product of evolution, or rather that it has evolved
in response to the changing needs of mankind ; as a believer
in the evolutionary hypothesis, he would have perceived that
both man and his moral scheme have gone in a particular
direction of necessity for the most part, and but seldom of
choice. Nietzsche would have seen that the Will to Power, as
he designated what others have called Deity, or causa causans
or to which some other name has been given, was the driving-
power sweeping relentlessly on, and that man, in order to save
himself from being engulfed, had to accommodate himself in
the best way he could to the torrent. If he called the hasty
make-shifts of which he made use “ codes of morality,” he may
yet be satisfied—the will-to-life still remaining—that at the
least they have enabled him to survive and to lord it over the
other animals. The crude form of society which Nietzsche
advocated progression—or return (?)—to would hardly have

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appealed to him in a less sanguine mood. He would have felt
a little dubious about adopting as a basis for his social recon¬
structions the rather ex parte views of Theognis of Megara,
who was unlikely to take a favourable view of the doings of
the democracy after they had made things rather unpleasant
for him.

Nietzsche’s ragings against the moral teachings of the
Sermon on the Mount, and against Christian ethics in general,
are of use if they make it clear to people that they seldom
observe to their full extent the dictates of their accepted code.
Some endeavour to follow completely the teachings of Christi¬
anity ; these are few in number. Others believe that they do
so follow them, although actually they do not; and these
deceive themselves. Yet others simulate conformity ; these
are the hypocrites who deceive—or try to deceive—their neigh¬
bours. Nietzsche worried himself unnecessarily, however, if
he imagined that Christianity, even if it connotes to many a
large proportion of quietism, had sapped the energy of men.
Events in Europe might have sufficed during his life-time to
prove that if the Bible was in one hand—and that hand per¬
chance a “mailed fist”—the sword was grasped firmly enough in
the other. Had he lived he would have seen the country
which gave birth to Luther well in the forefront of the battle,
forgetting neither Bible nor sword, and led, somewhat after the
fashion of the Duke of Plaza Toro, by him whom Nietzsche
described as a “ canting bigot.” The day may come when the
essential morality of the Christian religion—which is but saying
the morality of many high-thinking, honourable men from ages
long prior to the Christian era—may be practicable. That it is
not so yet is not an argument against it, but, perchance, rather
against our over-vaunted civilisation. But that the day will
come when Nietzsche’s fever dream of the time when the
reign of the supermen will begin upon earth we have little
warrant and less inclination to believe than that we shall come
to a realisation of Utopia, or the New Atlantis, or of the City
of the Sun.

Many a stone has been cast at Nietzsche since his first
published work appeared; and many of these missiles have
been hurled with all the bitterness of ignorance. That much
is certain from the crude notions which prevail in regard to his
teaching. He is credited with all the pessimism of Schopen-

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hauer, though he broke away from the teachings of his master,
and though his own doctrine of the further evolution of man into
the superman—however pitiless his notions in regard to the
means for the attainment of that objective—may be more
rightly designated as optimism ; and, to mention no others, he
is looked upon by many as one of the apostles of German
culture, though he denounces that culture and all its works
roundly and in no measured terms. Finally, if the Prussian
military party have arrogated to themselves the attributes of
the “ blonde beast,” and if they consider that by them, as if by
an oligarchy of supermen, the Will to Power is chiefly to be
shown, they will find little warrant for such belief in themselves
as the salt of the earth in the writings of Nietzsche. Never¬
theless the trend of affairs in Germany of recent years may well
serve to illustrate the perniciousness of doctrines which might
tend towards such an exemplification as that of a ruling class
of Prussian military “ supermen ” enforcing their will, or
“ master-morality,” upon the rank and file, the “ herd ” of the
German people, whose actions are influenced by a “ slave-
morality.” The German nation would resent such an applica¬
tion of Nietzschean rules to themselves ; equally the other
European races resent the dominance of the German nation,
who also are apparently desirous of becoming something in the
nature of supermen in comparison with their neighbours. It is
as idle to deny that such inferences might be drawn from
Nietzsche’s teaching as it would be to assert that he had any
intention of such an application of his doctrines regarding the
superman. When he contemplated a further and higher evolu¬
tion of man, he had not his own countrymen in mind as the
highest product of evolution at the present time.

It is almost certain that many who criticise Nietzsche have
not troubled to become adequately acquainted with his
writings ; and this is likely to continue to be so. His mode of
expressing himself in almost disconnected aphoristic para¬
graphs deters many people from continued study of his
writing ; for, however much Nietzsche may have desired to
follow in the footsteps of the brilliant La Rochefoucauld, this
method is not the best for subjects requiring elaboration. Yet
Nietzsche is not an obscure writer, he is no mystic ; there is
seldom any difficulty in understanding what he says. It is
only necessary to compare him with some of his metaphysical

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BY HUBERT J. NORMAN, M.B.

countrymen—or with metaphysicians of other nationalities for
that matter—to realise this. The misfortune is that although
the bricks are there, well-formed for the most part and only occa¬
sionally faulty in shape, the workman had not the concentration
of purpose, the training, or the strength to build them into a
coherent whole.

Part III.—Other Views regarding his Mental State.

It has already been shown that Nietzsche’s mental trouble
was not—as some have wished to prove—confined to the last
eleven and a half years of his life, but that the disorganising
influence was at work from a comparatively early age. Also
it has been admitted that the existence of this instability does
not necessarily rule Nietzsche out as a thinker, but it has been
pointed out that it behoves us to exercise more than usual
caution—especially in regard to his later writings (5 7)—before
we adopt his conclusions. The particular form of mental dis¬
order with which he was afflicted has, it is hoped, been
clearly demonstrated. It has been necessary to deal at some
length with the earlier attacks, as, when the final breakdown
took place in 1889, the later stages suggested to some persons
general paralysis of the insane (58): such symptoms as the
“ convulsions,” the unsteadiness of gait, the alteration of hand¬
writing, the exalted ideas. Even if such a condition had,
however, eventually supervened, it does not in any way contro¬
vert the facts already adduced in support of the contention
that Nietzsche had many years previously exhibited nervous
instability. The length of the final stages—eleven and a half
years—is also very much against the theory of general para¬
lysis of the insane; it is quite in accordance with what we know
of the terminal dementia associated with intermittent insanity
(59). Convulsions, apart from other physical signs, are not, as
is well known, by any means pathognomonic of progressive
paralysis. There are, in addition to those associated with
epilepsy, hysteria, etc., those described as idiopathic (6o), and
Clouston records a rare form of melancholia in which con¬
vulsions occurred (61).

Ireland comes to the following conclusion: “His was the
condition described as griibelsucht , folic de doute, the anguish
of doubts.” This was, however, merely one phase of his

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FRIEDRICH NIETZSCHE,

[Jan.,

morbid history ; and, indeed, a little later in the same essay,
Ireland draws attention to the other aspect of his mental con¬
dition without linking up the phases into what may be described,
in Nietzsche’s own terminology, as an “eternal recurrence.” (This
same doctrine of “ eternal recurrence ” is, by the way, a
curiously apposite doctrine for one who was subject to such
marked alternating phases.) Ireland thus describes Nietzsche’s
exalted state: “ The restless working of his intellect was
always accompanied by exaltation of the affective faculties ;
the power of correct reasoning slowly decayed, and the bonds
of restraint became weaker. This aggressiveness and egotism
became more and more prominent ” (62).

Miigge informs us that Dr. Binswanger, of Jena, under whose
care Nietzsche was for a time, “ diagnosed the breakdown as
atypical, not progressive, paralysis ” (63). From which we
gather little as to the actual condition, except that it was not
general paralysis of the insane; exactly what maybe meant by
“atypical” is certainly not obvious. It is strange, however,
that a fellow countryman of Kraepelin should not have been
impressed by the resemblance of the symptoms in Nietzsche’s
case to those described by Kraepelin.

Nordau apparently also lost sight of the condition in its
entirety, and confined himself to describing various symptoms
associated with it much as Ireland has done. He speaks of
“ Nietzsche’s intellectual Sadism, and his mania of contradiction
and doubt, or mania for questioning. In addition to these he
evinces misanthropy or anthropophobia, megalomania, and
mysticism ” (64). He even goes to the length of stating that
“the real source of Nietzsche’s doctrine is his Sadism” (65).
He bases this theory upon certain passages in which Nietzsche
enlarges on the “ feeling of content,” the “ voluptuousness,”
associated with the infliction of pain. These passages are more
particularly to be found in the later works. Even if, then, it
were to be admitted that Nietzsche experienced some degree
of gratification from the imaginative contemplation of cruelty
and the infliction of pain at certain times, it would not warrant
the assertion that it formed the basis of his doctrine (66).
That many of his sayings justify the inference is none the less
true: “ Pain is a civilising factor of the first rank; it is the
necessary pre-condition, and the inevitable accompaniment, of
pleasure and the affirmation of life. This is,” says Bloch, “the

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BY HUBERT J. NORMAN, M.B.

central idea of the philosophy of Nietzsche ” (67). The mis¬
anthropy, the megalomania, and the mysticism which Nordau
calls attention to were also merely symptomatic of particular
phases, and they were not, as we have seen, invariable charac¬
teristics of Nietzsche’s mental state.

Mencken says that “ from his youth onward, Nietzsche was
undoubedly a neurasthenic ” ; he draws an interesting com¬
parison between the mental state of Nietzsche and that of
Herbert Spencer, and suggests that “each was the victim of
specific organic diseases.” He adds : “ Nietzsche was an
hysteric in 1875, and by 1880, as his letters show, he was
already exhibiting symptoms of melancholia. . . . Ever

and anon the gorgeous egotism of the man would flash forth
and give him comfort” (68). This is a frank acknowledgment
of the prolonged nature of the nervous disorder from which
Nietzsche suffered, and the description of the condition approxi¬
mates closely enough to that which has been given in the pre¬
ceding pages for the resemblance to be noticeable.

According to Braudes, it was “ at the close of the year 1888
this clear and masterly mind began to be deranged,” and he
apparently bases this exaltation upon the fact that “ signs of
powerful exaltation only appear in the last letter but one, and
that insanity is only evident in the last letter, and then not in
an unqualified form ” (69). (Braudes refers here to the letters
written by Nietzsche to him.) That this is an unsatisfactory
method of deciding the question at issue only needs to be
stated to become at once apparent. Yet Nietzsche had stated
in an earlier letter (May, 1888) : “ The history of my springs,
for the last fifteen years at least, has been, I must tell you, a
tale of horror, a fatality of decadence and infirmity ” (7o).
Nietzsche realised, if others could not, the direction in which
he was tending ; the end only too lamentably justified his
apprehensions.

References.

(1) Frau Forster-Nietzsche.— The Young Nietzsche , pp. 1 and 8,
London, 1912.

( 2 ) Ibid., p. 6.

(3) M. A. Miigge.— Friedrich Nietzsche, p. 15, London, 1908.

(4) Forster-Nietzsche.— Op. eit., p. 15.

(5) D. Halevy.— The Life oj Friedrich Nietzsche, p. 19, London, 1911.

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FRIEDRICH NIETZSCHE.

[Jan.,

(6) Forster-Nietzsche.— Op. cit., p. 16.

(7) Miigge.— Op. cit., p. 15.

(8) Forster-Nietzsche.— Op. cit., p. 18.

(9) William W. Ireland.— Friedrich Nietzsche, Jotirn. Ment. Set'.,
vol. xlvii, p. 1, January, 1901.

(10) Forster-Nietzsche.— Op. cit., pp. 63-64.

(n) Forster-Nietzsche.— Op. cit., pp. 99 and 101.

(12) Forster-Nietzsche. — Op. cit., p. 243.

(13) Forster-Nietzsche.— Op. cit., p. 298.

(14) Forster-Nietzsche.— Op. cit., p. 329.

(15) Forster-Nietzsche.— Op. cit., p. 339.

(16) Forster-Nietzsche.— Op. cit., p. 348.

(17) Hal6vy.— Op. cit., p. 193.

(18) Ibid., p. 205.

(19) Ibid., p. 210.

(20) Halevy.— Op. cit., p. 211.

(21) Hal6vy.— Op. cit., p. 229.

(22) Ibid., p. 232.

(23) Haldvy.— Op. cit., p. 234.

(24) Ibid., p. 251.

(25) Halevy— Op. cit., p. 254.

(26) Ibid., p. 257.

(27) Halevy.— Op. cit., pp. 260-261.

(28) Halevy.— Op. cit., p. 265.

(29) Ibid., pp. 264-265.

(30) Halevy.— Op. cit., p. 277

(31) Ibid., p. 280.

(32) Haldvy. — Op. cit., p. 286.

(33) Halevy.— Op. cit., p. 294.

(34) Halevy.— Op. cit., p. 319.

(35) Hal6vy.— Op. cit., p. 338.

(36) Ibid., p. 345.

(37) Halevy.— Op. cit., p. 351.

(38) Miigge.— Op. cit., p. 85.

(39) Hal6vy.— Op. cit., p. 361.

(40) Frau Forster-Nietzsche.— The Young Nietzsche, pref., p. vii.

(41) M. A. Miigge.— Friedrich Nietzsche, p. 96, London, 1908.

(42) Ibid., p. 93.

(43) Miigge.— Op. cit., p. 94.

(44) Daniel Halevy.— The Life of Friedrich Nietzsche, p. 346,
London, 1911.

(45) The Young Nietzsche, p. 237.

(46) Ibid., p. 375.

(47) Gould, G. M.— Biographic Clinics, vol. ii, pp. 285-322, London,
1904.

(48) Nordau, Max.— Degeneration, pp. 415-472, 6th edit., London,
1895.

(49) The New Statesman, October 17 th, 1914.

(50) Genealogy of Alorals, p. 58.

(51) Kraepelin, E.— Lectures on Clinical Psychiatry, pp. 77-78, Eng.
trans., London, 1906.

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19 IS-] HEREDITARY TRANSMISSION OF EPILEPSY. 91

(5 2 ) Mencken, Henry L. — 7 'he Philosophy of Friedrich Nietzsche ,
London, 1908, p. 51.

(53) Halevy.— Op. cit., p. 234.

(54) Halevy.— Op. cit., p. 213.

(55) Mencken.— Op. cit., p. 23.

(56) Mencken.— Op. cit., p. 53.

(57) This is the opinion held by Havelock Ellis in his essay on
Nietzsche. “ It is during this period (after Zarathustra ) that we
trace the growth of the magnification of his own personal mission which
finally became a sort of megalomania.” Affirmations , p. 37, London,
1898.

(58) Halevy.—Op. cit., p. 351.

(59) Stoddart, W. H. B.— Mind and its Disorders, p. 232, 2nd edit.,
London, 1912.

(60) Dictionary of Psychological Medicine, “Convulsions, Idiopathic.”

(61) Clouston.— Mental Diseases , p. 94, 6th edit., 1904.

(62) Ireland, William W.—“Friedrich Nietzsche," fourn. Merit. Sci.,
vol. xlvii, p. 26, January, 1901.

(63) Mtigge.— Op. cit., p. 92.

(64) Nordau, Max.— Degeneration , p. 465.

(65) Ibid., p. 451.

(66) For a description of this perverse mental state see von KrafTt-
Ebing’s Psychopathia Sexualis, p. 118 et seq., Eng. trans., 12th edit. ;
also I wan Bloch, The Sexual Life of our Time , p. 557 et seq.

(67) Bloch.— Op. cit., p. 558.

(68) Mencken, H. L.— The Philosophy of Friedrich Nietzsche, pp. 51-
52, London, 1908.

(69) Brandes, George.— Friedrich Nietzsche, pp. 97 and 98, London,
1914.

(70) Brandes.— Op. cit., p. 85.

(') Communication to the Autumn meeting of the Medico-Psychological Asso¬
ciation, St. Luke’s Hospital, October 8th, 1914.

The Hereditary Transmission of Epilepsy. (’) By M. Abdy
Collins, M.D., Medical Superintendent, Ewell Colony for
Epileptics.

Mr. President and Gentlemen,—The subject that I propose
to bring to your notice to-day—namely, the hereditary trans¬
mission of epilepsy—is one of extreme interest and importance
at the present time in this country, where, owing to recent
legislation, public attention has been strongly focussed on the
question of transmitted defect. The results that I have obtained
have been a matter of considerable surprise to me, and I am
anxious to obtain the experiences of others in this matter.

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HEREDITARY TRANSMISSION OF ETILEPSY, [Jan.,

I am dealing with the subject from two points of view—(i)
the defects found in the ancestors of my patients, and (2) the
presence of epilepsy in the descendants.

I have confined myself entirely to epilepsy in the descendants,
as that is a disease in which accurate information is more readily
obtained, and, above all, chiefly concerns us. I should like to
point out that the various neuroses and minor defects cannot,
in my opinion, be accurately estimated, as so little importance
is attached to them by relatives that anything like completeness
of history is quite unobtainable ; but nevertheless no one who
frequently interviews the relatives of epileptics can fail to be
impressed with the many deficiencies, both mental and physical,
that are met with in many of them. On the other hand, however,
one does from time to time meet with healthy families and
sound ancestry with the epileptic patient as the only evident
defect. A large proportion of my cases are late epilepsy, that
is, epilepsy starting after twenty-five years of age, and a still
larger proportion of cases starting after twenty, that is when we
come to consider the married, with whom my figures are chiefly
concerned. In these cases alcohol and syphilis have played a
prominent part as causative agents, but I cannot agree with the
statement that all epilepsy starting after thirty-five years of age
is syphilitic in origin, though often it is so. I bring before you
figures relating to two series of cases. In the first 177 cases
I have traced the ancestry only, and have also divided them into
three groups, according as to whether the epilepsy started before
ten years of age, between ten and twenty-five years of age, or
after twenty-five years.

In the second group of cases, 420 ,1 have particulars regarding
epilepsy in the offspring also, and I have separated males from
females.

(1) In 177 cases, an ancestral history of defect was obtained
in 101 cases, or 57 per cent ., but many of the histories were
wanting in detail, and the proportion should undoubtedly be
much higher. This defect was alcoholism in the parent or
grandparent in 57 cases, or 32^2 per cent, of the total ; it was
epilepsy in the family in 37, or 22 percent . ; insanity in the
family in 21, or 12 per cent .; and neurosis recorded in 9.

Dividing these cases into groups, we find—

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BY M. ABDY COLLINS, M.D.

Alcohol

heredity.

Epileptic.

Insane.

Per cent.

Early epileptics (61 cases)

30 .

25 .

I 2

Adolescent epilepsy (80 cases)

34 •

l6 .

I I

Late epilepsy (36 cases)

34 •

25 .

As will be seen from these figures, the defect is often more
than one factor.

It is striking that adolescent or ordinary idiopathic epilepsy
should present the lowest percentage of epileptic heredity, and
attention will be called to this later.

(2) To consider now the second series of 420 cases—320
males and 100 females. Of these 320 males a history was
obtained from the friends in 261 cases, from the patients only
in 54 cases, and not at all in 5 cases, owing to mental defect
of the patient. A defect in the ancestors or collaterals is recorded
in 162, or 50 per cent. Of these it is parental alcoholism in
44 per cent ., or 72 cases ; it is epilepsy in 46 per cent., or 76
cases, parent or grandparent 32 times, brother or sister 32 times;
insanity is given in 74 cases, or 45 per cent. There is more
than one of these factors in many cases, and both parents were
drunkards 10 times, both parents epileptic once, grandparent
and parent epileptic 4 times, and grandmother and great¬
grandmother once. Of the 100 females a defective heredity is
given in 52—in the parent or grandparent the defect is present
37 times, and in 8 cases it is a brother or sister. Epilepsy in
near relatives is noted in 27 cases—in parent or grandparent
12 times, and in both parents once. (Here all the children are
epileptic.) In one case the maternal great-grandmother and
grandmother are epileptic, the mother is healthy, and the patient
is the only one of a family of eight who is affected ; she has
had an illegitimate child. Epilepsy in three generations is noted
3 times; alcoholism occurs in the parents 28 times; insane
relatives are noted 21 times; in 24 cases the history is deficient,
and in 11 none was obtained at all.

The comparative figures for the two sexes are :

Males.

Females.

Per cent.

Epilepsy .

Alcohol

. 22

Insanity

• 23

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94 HEREDITARY TRANSMISSION OF EPILEPSY. [Jan.,

With regard to parental alcoholism, it is noteworthy that
of the 72 male cases the heredity is paternal only in 54, and of
the 28 females it is paternal only in 22. This suggests that it
is not the alcohol itself which is responsible as a poison, but that
the habit of alcoholic excess is due to a nervous deficiency of
which epilepsy in the child is only another manifestation.

Next, as regards the offspring of these 420 who are the
patients at the present time at the Colony, the most striking
point is the small proportion of epileptics who are married ; of
320 males 61, or 19 per cent, only, and of the females 17, or
17 per cent, only, are married.

A year’s admissions to all the London County Asylums, who
are drawn from the same class, shows that of 1463 males 863,
or 59 per cent., and of 1650 females 1045, or 63 per cent., are
married. This is a very great difference ; and, further, of the
61 married male epileptics in only 20, or about 6 per cent, of
the total, did the epilepsy start before the age of twenty-five
years, and in only 9 cases did it start before the age of twenty
years. Only 4 males whose epilepsy started between ten and
twenty years of age are married.

Of the females married, only 8 had fits before twenty-five,
and 7 of them before twenty years.

These 78 married epileptics have at the present time 197
living children ; 10 have had no children.

In 8 cases no information is available ; in 44 cases none of
the children are affected ; in 6 cases fits are recorded in one or
more children ; and in 10 cases deaths of children from con¬
vulsions are recorded (in some cases many of the children).
Of offspring actually living who are, or have been, affected with
epilepsy only 5 children are recorded, and I have no reason to
doubt the accuracy of that figure.

Probably many other defects are present, and epilepsy may
occur later in others, but the present condition of 425 patients,
with 197 descendants only and 5 epileptics, seems to indicate
that other causes than direct heredity of epilepsy must be
responsible for the continuance of the malady.

(') A paper read before a meeting associated with the International Congress
of Medicine, 1913, and published in Epilepsia, vol. iv.

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1915]

INSANITY IN THE HIGHLANDS.

Some Considerations regarding the Family History of
Insanity in the Highlands By T. C. Mackenzie,
M.D., F.R.C.P.E., Medical Superintendent, District

Asylum, Inverness.

The Inverness Lunacy District, which was formed after the
passing of the Lunacy Act of 1857, comprises the four counties
of Nairn, Inverness, Ross, and Sutherland, and is of very large
extent. Its area is, roughly, one-third of the total area of
Scotland, and includes the greater part of the Highlands. Its
population, on the other hand, is extremely sparse, and has
been steadily decreasing during the last fifty years. It is a
district in which there has been much intermarriage of relatives,
and which is less open and accessible than most of the rest of
Scotland to the factors that have brought about such great
changes in the general life of the country during the last fifty
years. In recent years, however, the extension of railways,
and the wide use of motor cars, have done much to diminish
this degree of isolation and remoteness.

The following remarks relate to 226 cases, 119 male and
107 female, who have been admitted to the asylum during the
last four years. The total number of admissions for that
period was 613, and out of that number a definite family
history of insanity was obtained in these 226 cases. Inquiry
was made verbally and also by means of a form, which was
sent to the nearest known relative when the patient was
admitted, requesting information on matters of personal and
family history. The returns in the great majority of cases
were definite and reliable, and in many cases was readily
verified from the asylum registers. Some were not regarded
as such and were discounted, and a few, from the very serious¬
ness of their statements, were not without their amusing side,
as in the case of one man, who replied to the inquiry as to
whether there had ever been any previous mental disease or
disturbance in his family, his sister just having been admitted,
that “ there was never any such thing, and the family history
goes back 800 years and more.” We are proud of our descent
in the Highlands!

Study of the returns obtained in these 226 cases indicates
that the patients may be grouped into four principal divisions,
according as—

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96 INSANITY IN THE HIGHLANDS, [Jan.,

(1) Relatives had previously been in the asylum, but had
been discharged.

(2) Relatives were defective or of unsound mind, but were
uncertified.

(3) Relatives were present in the asylum on admission of
the patient.

(4) Relatives had died in the asylum.

From the following table it will be seen than in 7 5 of the
cases, or one-third of the total number, there had previously
been relatives of the patient in the asylum ; in 56, or one-
fourth of the cases, there were relatives who were defective or
unsound in mind, but had not been certified ; in 29, or one-
eighth of the cases, relatives were present in the asylum when
the patient was admitted; and in 24, or one-ninth of the cases,
relatives of the patient had died in the asylum.

Cases with relatives
formerly in asylum.

Cases with relatives
defective or unsound,
but uncertified.

Cases with relatives
present in asylum.

Cases with relatives
who had died in
asylum.

Male.

Female

Total

Male.

Female

Total.

Male.

Female.

Total.

Male.

Female.

Total.

l 6

In the case of the first group, among the relatives who were
found to have been in the asylum and discharged from it prior
to the admission of the patient, were 4 fathers, 11 mothers,
19 brothers, 17 sisters, 2 sons, 1 daughter, 16 uncles, 10
aunts, 10 cousins, and others, including a grandmother and a
grand-aunt.

In the second group, the relatives included 9 fathers, 14
mothers, 2 daughters, 10 sisters, 12 brothers, 8 aunts, 7 uncles,
and other specified relatives, and, in addition, the returns in
the cases of 9 patients, not included in the above figures, were
to the effect that several members of the family were weak-
minded but uncertified.

In the third group, among relatives present in the asylum on
admission of the patient were 1 father, 3 mothers, 7 brothers,
6 sisters, 2 daughters, 1 uncle, 1 aunt, 8 cousins, 2 nephews.

In the fourth group, among the relatives who had died in
the asylum, were 1 father, 8 mothers, 1 brother, 3 sisters,

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r 9 1 5-3

BY T. C. MACKENZIE, M.D.

i grandfather, 2 grandmothers, 7 uncles, 2 aunts, 2 cousins and
others.

These four groups account for 184 of the 226 cases, and
the above figures show that the insane members of the families
represented by these 184 cases include 15 fathers, 36 mothers,
39 brothers, 36 sisters, 31 uncles, 21 aunts, and these by no
means exhaust the list.

The remaining 42 cases fall into eight groups, in six of
which two of the original groups are combined, and two of
which contain three of the original groups.

The six are as follows :

Cases with relatives—

(a) Formerly in asylum.
(4) Unsound but uncer¬
tified.

Cases with relatives—

(<j) Present in asylum.

(4) Formerly in asylum.

Cases with relatives—

(a) Present in asylum.

(4) Died in asylum.

Male.

Female.

Total.

Male.

Female.

Total.

Male.

Female.

Total.

Cases with relatives—

(a) Present in asylum.

(4) Unsound but uncer¬
tified.

Cases with relatives—

(a) Formerly in asylum.

(4) Died in asylum.

Cases with relatives—

(a) Died in asylum.

(4) Unsound but uncer¬
tified.

Male.

Female.

Total.

Male.

Female.

Total.

Male.

Female.

Total.

In these six compound groups, representing 38 cases, among
the relatives in the families involved are 5 fathers, 9 mothers,
13 brothers, 15 sisters, 2 sons, 11 uncles, 7 aunts, 12 cousins,
3 nephews, 2 nieces.

Of the four remaining cases, 3—1 male and 2 females—
had relatives who (a) had formerly been in the asylum, (£) were
unsound but uncertified, (<r) were present in the asylum on
admission of the patient.

The relatives in this group included I mother, 3 brothers,
3 sons, 3 sisters, and 1 cousin.

The last case is that of a female, whose grandmother and
maternal aunt died in the asylum, whose nephew was in the
asylum when she was admitted, and whose father and two
brothers were of unsound mind or defective, but uncertified.

LX 1. 7

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98 CRIME, ALCOHOL, AND ALLIED CONDITIONS, [Jan.,

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In the great majority of the cases, 166 out of 226, the
patients were first admissions, but the total number of cases
includes 38 with one previous admission, 12 with two, 5 with
three, 2 with four, 2 with five, and 1 with eleven previous
admissions.

The foregoing facts in relation to the family history of
patients admitted to the asylum in recent years suggest the
conclusion that a comparatively small number of families
and individuals within the district is responsible for a relatively
high contribution to the total number of cases coming under
care and treatment ; in other words, that in the general popula¬
tion there are certain strains, the members of which are specially
prone to mental disease.

With regard to the main types of mental disease most pre¬
valent within the district, analysis of the 765 cases admitted
during the last five years, in all of which the diagnosis of the
mental condition has been made by myself, shows that 408
were cases of melancholia, 200 of mania, 97 of dementia,
37 of congenital mental deficiency, 20 of general paralysis,
and that 3 patients were returned as not insane. Epilepsy
was found in 2 1 of the cases.

In conclusion, I think the fact is worth recording that at
present there are in the Inverness District Asylum only six
cases of general paralysis, in an asylum population of over
700, and that the patients are all males. It is of much signi¬
ficance that they have all spent many years of their lives out
of the Highlands, one as a seaman all over the world, one
in Johannesburg, two in America, one in Glasgow and
Liverpool, and one in Glasgow and Edinburgh.

( l ) Abstract of a paper read at the Annual Meeting of the British Medical
Association, Aberdeen, 1914 .

Crime , Alcohol and other Allied Conditions in Stafford¬
shire. By M. Hamblin Smith, Medical Officer, H.M.
Prison, Portland.

The relations between alcohol and criminality have been
considered by many students of such subjects, and figures
relating thereto have been worked out by more than one
observer. But these figures have applied either to some large
city, or to England and Wales as a whole. No statistics have

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1 9 1 5-1

BY M. HAMBLIN SMITH.

been (so far as I know) compiled for such a county as Stafford.
In this paper I have endeavoured to supply this omission,
having had some opportunity of considering the question while
serving as Medical Officer of H.M. Prison at Stafford. The
county of Stafford is, in some respects, peculiar, inasmuch as
the density of its population varies greatly in different districts,
and its industries are very diverse. The extreme south of the
county abuts on Birmingham, and considerable parts of the
county area are now contained in “Greater Birmingham.” In
the south and south-west of the county are the various towns
and districts which make up the “ Black Country.” Towards the
north of the county lies the densely-populated area of the
“Potteries.” Mining districts are scattered in various parts, and
there are two boroughs with distinctive industries of their own
—Stafford (boots and shoes), and Burton-on-Trent (the
metropolis of beer). The remainder of the county consists of
agricultural and grazing land.

The criminal statistics have been dissected by dividing them
into classes corresponding to the police-courts from which the
offenders were committed to prison. As a consequence parts
of the county had to be eliminated, for the Birmingham
district, Burton-on-Trent, and a small part of the extreme
south-west of the county only commit cases to Stafford Prison
for trial at Assizes and Sessions. But there remains a large
and varied district with a population of nearly a million inhabi¬
tants (921,000). This district I have divided into the following
areas, the populations being those of the 19 11 census, reckoned
to the nearest thousand :

Population.

(1) The “Black Country" —comprising the county

boroughs of Wolverhampton and Walsall, and
the petty sessional districts of Wolverhampton,

Willenhall, Bilston, and Sedgley . . . 317,000

(2) The “ Potteries ”— i.e. the county borough of

Stoke-on-Trent ...... 235,000

(3) “ Mining districts ’’—comprising the borough of

Newcastle-under-Lyme, and the petty sessional
districts of Pirehill North, Rushall, Penkridge,
and Cannock ...... 176,000

(4) “ Agricultural districts ”—comprising the borough

of Tamworth, and the petty sessional districts

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IOO

CRIME, ALCOHOL, AND ALLIED CONDITIONS, [Jail.,

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Population.

of Cheadle, Eccleshall, Stone, Uttoxeter,

Tam worth, and Stafford (not including Stafford
Borough) ....... 86,000

(5) “Mixed districts ”—to some extent agricul¬

tural, but also contain a number of mining
villages ; they comprise the city of Lichfield,
and the districts of Rugeley and Lichfield . 44,000

(6) Stafford Borough —a manufacturing town . . 23,000

(7) Leek —this is mainly an agricultural and moor¬

land district, but the population is largely
composed of the silk-manufacturing town of
Leek ........ 40,000

921,000

Of course this, like any other classification, is more or less
imperfect. But I venture to contend that the districts as
arranged above have each special characteristics which
differentiate them from each other.

There is a considerable Irish element in the population of
the Potteries, and I am informed that a number of the Leek
people have French blood in their veins, being descended from
Huguenot refugees. There is a small coal-field in the Cheadle
district, and a number of colliery villages near Tamvvorth, but
in the county of Warwick. The bearing of these two last facts
will be seen later.

The period of which I have brought under review comprises
the years 1911, 1912, and 1913. I have selected this period
for three reasons : ( a ) It was necessary not to take too long a
period, in order that administrative conditions might be similar;
(1 b) the pottery towns were federated into a county borough at
the end of 1910; ( c ) the period nearly corresponds with my
tenure of office at Stafford.

The railway strike occurred in 19 1 1, and the coal strike in
1912 ; the latter greatly affected Staffordshire. But neither of
these events had any appreciable effect on the criminal statistics,
which show a remarkable uniformity for each separate year.

I would remark that the boroughs of Stoke-on-Trent, Wolver¬
hampton, Walsall, and Newcastle-under-Lyme each maintain
a separate police force. The rest of the area is policed by the
county police force.

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PRINCETON UNIVERSITY

I9I5-]

BY M. HAMBLIN SMITH.

IOI

Classification of the offences. —I have divided the offences
into two main classes—“alcoholic” and “non-alcoholic”—on the
consideration as to whether or not alcohol usually figures as
an immediate cause of the offence. No such classification can,
of course, ever be wholly accurate ; some offences placed under
either heading should properly be under the other. But such
cases of erroneous classification would probably be found to
balance each other in the long run ; and I venture to think
that my classification is not an unreasonable one. Both classes
have various sub-divisions, arranged as follows :

(a) Alcoholic offences , i.e., offences in which alcohol is in¬
variably, or very frequently, an immediate cause.

(1) Drunkenness, including “drunk and disorderly," “drunk
and riotous,” “drunk on licensed premises,” etc.

(2) Assault, including “indecent assault” and “wounding”
in its various degrees.

(3) Wilful damage.

(4) Neglect of, and cruelty to, children.

(5) Other offences, such as indecent or obscene language,
indecent exposure, etc.

(b) Non-alcoholic offences , i.e., offences in which alcohol is not
usually an immediate cause.

(1) Burglary, including shop and warehouse-breaking, and
attempts thereat.

(2) Larceny, including “receiving,” “obtaining goods by
false pretences,” and similar offences.

(3) Vagrancy offences, including begging, sleeping out, dis¬
orderly conduct in the workhouse, etc.

(4) Other offences—a miscellaneous lot, comprising trespass,
gambling, and various other minor matters.

I have omitted all debtors and other “civil process” prisoners,
and, after some consideration, I decided to omit persons sent
to prison for failure to pay maintenance and bastardy arrears,
and for offences against the School Acts.

I have placed prostitution in a separate category. No doubt
it is often combined with drunkenness ; but it is so difficult to
say whether alcoholism is the cause or the result of the prosti¬
tution that I judged it best to classify these offences separately.

The number of prisoners coming within my classification
for the three years was 9,341 (males, 7,509; females, 1,832),
and give the following figures :

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102

CRIME, ALCOHOL, AND ALLIED CONDITIONS, [Jan.,

Table A.— Males.

Offences.

Alcoholic.

Non-alcoholic.

■

Assault.

Wilful damage.

Neglect of
children.

Other alcoholic
offences.

Total of alcoholic
offences.

Burglary.

Larceny, etc.

U •

r- ®

5 w

2 °

6 £

> 0

Other offences.

Total of non¬
alcoholic offences.

Black Country .

678

326

226

>377

534

232

407

1230

Potteries .

999

248

3 *

III

178

1567

3 8 3

453

>52

1038

Mining districts
Agricultural dis-

216

105

425

128

126

357

tricts

226

333

>15

139

316

Mixed districts .

135

208

181

Stafford Borough

131

>75

117

Leek district

108

Total .

2441

769

144

273

535

4162

>44

'356

>059

788

3347

Table B.— Females.

Offences.

Alcoholic.

Non-alcoholic.

«?

Wilful damage.

Neglect of
children.

Other alcoholic
offences.

Total of alcoholic
offences.

Vagrancy, etc.

Other non-alco¬
holic oflences.

Total of non-alco¬
holic offences.

«Q

Black Country .
Potteries .
Mining districts
Agricultural dis¬
tricts

Mixed districts .
Stafford Borough
Leek district

241

255

> 4 >

106

534

454

—

3 >

2 _

146

3 >

> >3

16 !

T otal .

670

>25

>37

291

1252

6 209

346

234

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PRINCETON UNIVERSITY

1 9 1 5-3

BY M. HAMBLIN SMITH.

103

Table C.— Giving the Percentage of “ Alcoholic Offences ” to
the Total Number of Offences.

Male

percentage.

Female

percentage.

Black Country.

Potteries.

Mining districts.

Agricultural districts ....

Mixed districts.

Stafford Borough ....

Leek district.

Whole Area.

The percentages for the males agree very closely with the
results obtained by Dr. J. Baker from the records of Penton-
ville Prison ( Proceedings of Brussels Penitentiary Congress ,
1900). The great influence of alcohol on female crime will be
noticed.

The alcoholic monthly averages show a rise during the
early months of the year, and a fall when the summer is over.
The curve for all non-alcoholic offences is much the same as
that for the alcoholic. The curve for offences against property
(burglary and larceny) is fairly constant throughout the year.
The peculiarity of the vagrancy curve is that it reaches its
highest point in January and its lowest point in December;
probably this is due to the effect of charity before and during
Christmastide.

Comparison betivcen the Incidence of Offences in Different

Districts.

Deductions here must be drawn with great caution. In
comparing the different figures it must be remembered that(i)
Police methods as to the arrest of offenders (particularly of
drunken offenders) vary; (2) Courts deal with offenders in very
diverse ways. Some courts make far more use of the “ proba¬
tion ” system than others do; and the figures only represent
those offenders who are sent to prison.

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PRINCETON UNIVERSITY

104 CRIME, ALCOHOL, AND ALLIED CONDITIONS, [Jan.,

The first point which comes out from a perusal of these
tables is the extremely bad figures given by Stafford Borough.
In this connection it must be remembered that (i) the totals

Diagram showing the Monthly Averages of Various Classes of
Offences [Male and Female together).

Upper thin line—all alcoholic offences. Upper thick line—all non-alcoholic
offences. Lower thin line—larceny and burglary. Lower thick line—
vagrancy.

are small, (2) the town is exceptionally well policed, (3) a
large amount of young female labour is employed in the shoe
factories, (4) possibly some of the prisoners from other districts
do not leave the town when released, but remain to commit
fresh offences within the borough.

The figures for the Potteries are bad. The population in

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PRINCETON UNIVERSITY

19 * 5 -]

BY M. HAMBLIN SMITH.

105

TABLES D and E, giving the Average Yearly Numbers per
100,000 of Population sent to Prison for Various Classes
of Offences from the Different Districts.

Table D.— Males. Table E.— Females.

■

All offences.

All alcoholic
offences.

All non-alcoholic
offences.

*-•

•

Burglary and
larceny.

All offences.

All alcoholic
offences.

All non-alcoholic
offences.

Assault.

Burglary and
larceny.

Black Country

274

144

129

Potteries ....

369

222

»47

Mining districts

147

«5

Agricultural districts

250

129

122

—

Mixed districts

294

157

137

—

Stafford Borough .

423

252

169

117

Leek district .

*54

Whole of area

272

150

121

this district is badly paid and ill-housed, and a large amount of
female labour is employed.

The agricultural districts give satisfactory results, and the
very low figures for the Leek district are very striking.

The figures for the mining districts are low, and this does
not agree with the statistics published for what are termed
“ mining counties.” The fact is that the word “ mining ” as
applied to a county is misleading. Mining may be a prominent
industry in a county, but there are always other important
industries ; and the mining population will always be found
grouped in large villages. It must also be remembered that
the miner is a well-paid worker, and probably, in many cases,
pays his fine instead of coming to prison. Also no female
labour is employed about the coal mines.

I have worked out the numbers of those committed for
alcoholic offences who were born outside the district in which
they were convicted.

The information as to birth-place depends on the prisoner’s
own statement, and is probably in many cases erroneous. The
labour involved in getting out the figures was considerable.
Unfortunately, I was moved from Stafford before I had time to
obtain the information for other classes of offences. Still, the

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106 CRIME, ALCOHOL, AND ALLIED CONDITIONS, [Jan.,

Table F. —Percentage of Alcoholic Offenders born outside
District of Conviction.

Males.

Females.

Black Country ....

Potteries.

Mining districts ....

Agricultural districts .

Mixed districts ....

Stafford Borough

Leek district ....

Whole area.

figures, as far as they go, are interesting. They bear out what
I said above as to one possible cause of the high criminal
figures for Stafford Borough. The high figures for the mixed
districts are due to the presence of a large military garrison in
Lichfield.

I venture to think that this line of inquiry is worth following
up on a larger scale in other places.

Occupations of prisoners. —Very little stress can be laid on
the occupations given by prisoners on reception. The great
majority of the men describe themselves vaguely as “ labourers.”
But I have enumerated the men who described themselves
as “ miners ” or “ colliers.” These men give the following
figures :

Table G.— Offences committed by Miners.

All alcoholic
otfencet.

Burglary and
larceny.

Vagrancy.

Other non-alco¬
holic offences.

Black Country

141

Potteries ....

356

Mining districts .

128

Agricultural districts .

Mixed districts

Stafford Borough

—

Leek district

—

692

180

201

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PRINCETON UNIVERSITY

1915] BY M - HAMBLIN SMITH. 107

A number of the offences in the last column of this table
were for poaching.

In the agricultural districts, more than half of these cases
of “miners” were committed to prison from Tamworth.
These were probably men who lived over the county border in
Warwickshire.

I am rather doubtful as to the correctness of the description
of “ miner ” given by many of the vagrancy cases.

I have been unable to obtain any accurate statistics of the
number of men actually employed as miners in the area with
which my figures deal.

Statistics of pauperism .—These have been obtained from the
Local Government Board’s half-yearly statement for the
paupers relieved on January 1st, 1914. A complete compari¬
son with the criminal statistics could not be made, for the
Poor Law Union areas differ in some cases materially from the
petty sessional districts. So far as a comparison can fairly be
made, the following figures are given for my areas :

Area.

Black Country.
Potteries.

Mining districts
Agricultural districts
Mixed districts
W f hole area

Number of paupers
per 100,000 of
population.

2,254
2,380
1,927
I >749
L 754
2,190

The figures for Stafford Borough could not be given sepa¬
rately, as for Poor Law purposes Stafford is contained in a large
country union. The Leek Union differed so greatly from the
Leek petty sessional district that any attempt at comparison
would have been unfair.

The figures show a high rate of pauperism where there is
a high rate of “ alcoholic ” offences (and hence presumably a
high rate of drunkenness). There is nothing strange or novel
in this conclusion.

Statistics of insanity .—These have been taken partly from
the Local Government Board’s statement, and partly from
information most kindly supplied by the Superintendents of the
Staffordshire County Mental Hospitals. So far as comparison
with the criminal statistics go, these figures are subject to the
same limitations as were the statistics of pauperism.

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108 CRIME, ALCOHOL, AND ALLIED CONDITIONS. [Jan.,

Area,

Numbers per 100,000 of population.

Insane paupers in
asylums and other
institutions.

Total number of
insane paupers
relieved.

Average yearly
admission rate into
asylums.

Male.

Female.

Black Country

292

316

276

Potteries

330

348

35 ‘ 2

327

Mining districts .

198

212

288

20'4

Agricultural districts .

239

250

285

Mixed districts

215

230

23-1

2 7'5

Whole area .

295

315

286

278

On the whole, these figures present a marked similarity to
those given by the pauperism statistics, and those for alcoholic
crime.

The peculiar differences for the male and female admission
rates in the mining, agriculture, and mixed districts will be
noted.

Conclusions .—We are, I think, justified in cautiously making
the following deductions:

(1) Alcohol is directly responsible for more than half of the
male prison receptions, and for a much larger proportion of
female receptions.

(2) Densely populated areas give the highest proportion of
alcoholic offences. This is especially the case where the
workers are ill-paid, and particularly where much female labour
is employed.

(3) A high rate of alcoholic offences is usually, but not invari¬
ably, accompanied by a high rate of non-alcoholic offences,and by
a high rate of crimes of violence, of pauperism, and of insanity.

(4) That there is no very marked relation between pauperism
and crimes against property.

I am indebted to the Prison Commissioners for permission
to publish this paper. And my best thanks are due to Dr.
J. W. S. Christie, Dr. J. B. Spence, and Dr. W. F. Menzies, of
the Stafford, Burntwood, and Cheddleton Mental Hospitals, for
their great kindness in obtaining some of the insanity statistics
for me; to Dr. A. Salter, for assistance in obtaining the
statistics of pauperism ; and to Dr. W. C. Sullivan, of the
Criminal Lunatic Asylum at Rampton, for much kindly criticism
and encouragement.

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PRINCETON UNIVERSITY

! 9 1 5-]

CLINICAL NOTES AND CASES.

IO 9

Clinical Notes and Cases.

A Case of Recurrent Purpural Eruption f) By Dr.
J. O’C. Donelan, Medical Superintendent, Richmond

Asylum, Dublin.

The case I venture to bring under your notice has been a
subject of much interest to me for some time past, chiefly
because of its obscurity, and now, with a view to obtaining
some information rather than throwing light on the subject, I
will give you its main features.

The patient was admitted to the Richmond Asylum, at the age of
thirty, suffering from mania a potu , in July, 1899. He soon recovered,
and resumed his occupation of car-driver. About nine months after he
was again admitted, and discharged in a few months. From the notes
he appears to have been first excited, violent, and restless, with hallu¬
cinations; then melancholic, and gradually regained his normal mental
balance, which was about the average of men of his class. He was
again admitted in 1901, suffering from his old complaint, but all sym¬
ptoms much worse than on the previous occasions; hallucinations of
sight and hearing were vivid and terrifying, he was acutely suicidal, yet
took his food fairly, and no organic defect was detected. After a little
he quieted down pretty well, but became extremely incoherent in his
speech, yet able to answer a definite question, and he began to do
some general work about the ward. No particular change was noticed
in his mental or physical condition for a long time.

About three years ago, he began to develop a strange mixture of
delusions of exaltation with those of depression, such as one often finds
in general paralytics, stating that he owned great property, wealth, and
horses, and generally promising great gifts at one moment, and the next
complaining that he had been robbed, was destitute and miserable.
Gradually he seemed to lose these definite delusions ; he ceased to be
able to occupy himself, and his mental state might be described as
mild secondary dementia.

At this time he used to walk aimlessly about the recreation ground,
earnestly but most incoherently discussing matters unto himself. It
was noticed one day that his face was extremely flushed, and, on exa¬
mination, his body was found to be covered with a bright red rash,
while his legs and arms were of a dusky hue, with minute petechiae at
the roots of the hairs, and irregular patches of subcuticular ha2morrhages
over shins and flexor aspect of forearms. His temperature, pulse, and
respiration rates were normal, and nothing abnormal was detected about
his heart. He was put to bed for observation, and in the course of
about twenty-four hours the bright rash had almost disappeared, leaving
a purpural mottling, which soon began through various colourings to
fade away. There being practically no constitutional disturbance, it

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I IO

CLINICAL NOTES AND CASES.

[Jan,

seemed to be a trifling matter, which had passed off. He was then
ordered up, but within an hour or two the rash reappeared, and the
purpural state of his legs, arms, shoulders, and chest became even more
marked than in the first attack. It was then noticed that his gums
seemed rather soft, and the condition was believed to be of the scurvy
class. He was put on lime-juice and iron and kept in bed, when, as
previously, recovery soon took place. Particular pains were taken to
ensure his having abundant vegetable dietary with his meat, but, to our
surprise, when he left his bed for even an hour or two, the flushing and
purpuric condition reappeared, and for quite two years it was found
that whenever he was out of bed for any length of time he developed
this peculiar condition.

Quite lately, some improvement has taken place so that it takes a
day or two to bring on the rash, and it is not so alarming-looking as it
used to be. Throughout there was not any marked tendency to
haemorrhage from mouth or nose. His appetite was fairly good, diges¬
tive functions and sleep of about average, pulse-rate usually but not
invariably increased to 85 or 90 with the onset of the rash. His normal
pulse-rate is about 70, and when in bed occasionally I have found it as
low as 58. Knee and eye reflexes were normal, while examination of
the blood revealed no abnormality. His skin is rather harsh, dry, and
inclined to be scaly, particularly about the elbows and knees, but not to
any greater degree than one frequently finds amongst the insane. At
present he is in a state of partial dementia; he can answer pretty
clearly regarding events previous to his mental breakdown, but his
mind is utterly blank as to recent occurrences. \

As to the physical nature of the case, I must admit that I
feel quite at sea, and I have failed to find out much light on
the subject. If the purpuric state occurred on the legs only
when the patient was going about, a simple explanation, of
course, would be that gravity raised the blood-pressure in the
limbs, causing the extravasation from the arterioles of the skin,
but would not account for the condition on the back of the
shoulders, neck, and arms, or the flushed state of the face and
head. Vaso-motor paralysis might be suggested, but then why
should it occur when the patient was about, and disappear
when recumbent? The blood itself was not found to be
abnormal, nor did the patient look anaemic at any time.

( l ) A Paper read at the Autumn Meeting of the Irish Division on November 5th,
1914.

Discussion.

Dr. Rainsford pointed out that purpura and other skin eruptions were of
frequent occurrence in imbeciles and idiots of whose ailments he had large expe¬
rience. He considered the condition met with in Dr. Donelan’s case due to alcohol.
There was no external haemorrhage, no rise of temperature, which was remarkable.
The case might possibly be one of “ peliosis rheumatica,’’ but in this condition

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* 915 ]

OCCASIONAL NOTES.

I I I

there would be a rise of temperature. The rash did not occur after maniacal
excitement.

Dr. Eustace wished to know if bromides had been administered, as he had seen
purpuric rashes appear after the exhibition of this drug in small doses, and
whether the rash had the appearance and characteristics of urticaria ?

Dr. Redington said that in two cases of mania in his practice he had observed
a rash of a purpuric character.

Dr. Gavin was of the opinion that the eruption was not caused by alcoholic
excesses in the patient, but was due to a vaso-motor disturbance.

Dr. Greene thought the paper was of great interest. He said he was not a
pathologist, and therefore he spoke with reserve on a very difficult question, but it
appeared to him that the symptoms described all pointed to an affection of the
arteries of the skin. If the internal blood-vessels were affected, those of the brain
would undoubtedly have suffered by the disease, and have produced apoplexy,
thrombosis, etc. The haemorrhagic spots he assumed were caused by effusions
from those blood-vessels which were especially supported by the musculature.
He believed the condition of Dr. Donelan's patient to be due to toxaemia, to which
was added the mechanical influence of muscular action in the superficial blood¬
vessels, causing extravasation and increased blood-pressure in this individual case.
He contrasted the symptoms of cases of purpura hamorrhagica under his care with
the symptoms present in Dr. Donelan’s case.

Dr. Leeper said that from the history of the case it appeared to him that, owing
to the alcoholic origin of the mental conditions, the patient’s blood-vessels were
diseased, and that a hsemolytic action was set up which produced the extraordinary
rash described.

Dr. Drapes contrasted the symptoms of scorbutus with those of purpura hamor-
rhagica with reference to Dr. Donelan's case.

Occasional Notes.

The Annual Meeting.

The Annual Meeting, held in the ancient and historic city
of Norwich, will rank amongst the most pleasurable memories
in the minds of those members who were fortunate enough to
be able to attend. The full literary programme it was found
impossible to carry out, partly from lack of time, and partly
because they were glad to exchange the task of intellectual
effort, owing to the rather oppressive atmosphere which pre¬
vailed indoors, for the more alluring social amenities which
were so generously provided for them by the kindness of their
hospitable friends of Norwich.

There are abundant features of interest to be found in the
old city and its neighbourhood. It is particularly rich in
buildings of architectural beauty, its magnificent cathedral taking
the lead, with its adjoining close, which were visited by pro¬
bably all the members. There are also many other churches
of great beauty, and the “ Strangers’ Hall ” was a centre of
general interest, with its wonderful collection of relics of a

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I I 2 OCCASIONAL NOTES. [Jan.,

distant past, many of them grotesque and with weird and
grumous associations. Norwich is a wonderful rose country,
and one of its special attractions in the summer season is the
wealth of bloom and the delicious fragrance with which the
whole region is permeated. It might well take the Duke of
Richmond’s motto as its own —En la Rose je fleuris.

The presidential address was worthy of the occasion and of
the man. The selection by the Association of the chief officer
of the Norfolk County Asylum as President, and its county
town as the seat of the Annual Meeting, was an appropriate
way of celebrating the centenary of the foundation of its
asylum. Dr. Thomson has for many years taken an active
part in the proceedings of the Association, of which he is one
of the most honoured members. He has raised the institution
with which he has been so long connected to a position of one
of the best managed asylums in the country. Over and above
what may be called his ordinary work he has interested
himself largely in the promotion of the further education of
those who purpose taking up psychiatry as their special branch
of medical practice, and has served on a committee having that
object in view, particularly as regards the granting by univer¬
sities of diplomas in psychiatry. Efforts in this direction have
been attended with very substantial success, a result which Dr.
Thomson and those who co-operated with him deserve to be
heartily congratulated upon.

The keynote of Dr. Thomson’s address is to be found in
his opening remarks : “ The commemoration of a centenary is
a hollow and useless proceeding unless, from a study of the
period under consideration, we gather and apply the wisdom it
teaches, and realise that it is merely a point d 1 appui for future
advance and extension.” In endeavouring to fulfil this object
he set himself no easy task. Yet those who heard the address,
and that larger audience who have the opportunity of reading
it in the pages of this Journal, will be prepared to admit that
he achieved his purpose admirably. The address is, in fact, a
deeply interesting summary of the progress of psychiatry during
the past century, at the commencement of which psychiatry
can hardly be said to have existed, and it may be looked upon
as almost the very youngest scion of the tree of medicine.
The tough, obstructive soil and undergrowth which, in the form
of baneful though time-honoured views as to the nature of

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PRINCETON UNIVERSITY

1915]

OCCASIONAL NOTES.

insanity, prevented its emergence had first to be cleared away,
and it was only when the doctrine of demoniacal possession
as the cause of insanity was questioned, and ultimately aban¬
doned, that psychiatry as a science became possible. The
cruelties practised on the insane by way of treatment were
mainly the result of the doctrine of possession. Men’s actions,
as a rule, conform to prevailing opinions, and, as Lecky, when
speaking of witchcraft, finely says: “There are opinions that
may be traced from age to age by footsteps of blood ; and
the intensity of suffering they caused is a measure of the
intensity with which they were realised.” However, it was the
sufferings of the insane, rather than suspicion of the unten-
ability of the popular doctrine as to the cause of insanity,
which in the first place appealed to the kindlier feelings of
compassionate persons. And so, as pointed out in the address,
in this, as in other movements of social reform, the philanthro- >
pist preceded the scientist.

Dr. Thomson gives a concise but lucid resumt of the various
important legal enactments bearing on the care and treatment
of the insane, the most important of which was the Act passed
in 1845 establishing the Lunacy Commission, an Act which
he designates as the “ Magna Charta ” of the insane. And
there are probably but few who would refuse to' acknowledge
the whole-hearted manner in which that important body has
striven to develop the greatest efficiency in the management of
our asylums. Dr. Thomson, in commenting on the provisions
of the Local Government Act of 1898, which transferred the
control of asylums from the magistrates to a Committee of the
County Council, speaks of the apprehensions felt at first that
“ the management might degenerate to the Poor Law institu¬
tion level,” the falsity of which, he says, experience has proved ;
and concludes that “ we can say that the people’s representa¬
tives have governed our asylums at least as wisely, sympatheti¬
cally, and generously as their predecessors.”

In dealing with the progress in knowledge of the nature and
treatment of insanity, Dr. Thomson makes a useful division of
the century into four equal periods, each characterised by
some special element of advance. The first of these witnessed
the dawn of legal enactments for the benefit of the insane
without any recognition of insanity as a disease of the brain.
The second was characterised by the abolition of mechanical

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restraint and coercive measures generally, and in this connec¬
tion he assigns the premier place to Mr. Gardiner Hill, assistant
in the Lincoln Asylum. An important incident of this second
period was the founding of the Medico-Psychological Associa¬
tion in the year 1840, which gave a great impetus to the then
recently adopted view that insanity was the outcome of disease
or disorder of the brain. During the third period asylums
attained a very high degree of excellence, as Dr. Thomson
says, “ all reasonable perfection.” The fourth period had for
its distinguishing feature the institution, on the initiative of the
Association, of an organised system of training of nurses and
attendants, and the granting of certificates of proficiency in
mental nursing ; also the establishment of pathological
laboratories in many of the large asylums, and, finally, the
inducing of several of our universities to grant diplomas in
psychiatry, in which Dr. Thomson himself took a great personal
interest, and with which the name of Dr. T. W. McDowall will
be for ever associated. This division into chronological periods
constitutes a valuable aid when we endeavour to recall the
successive stages in the progress of psychiatry.

One could not desire a better illustration of the march of
modern ideas as to the treatment of insanity than to walk
through the wards of Norfolk County Asylum. Especially
noteworthy is the “ Nurses’ Home,” not long erected, a really
home-like snuggery, to which the nurses can retire when off
duty. Perhaps there is no more striking mark of the progress
of psychiatry than the modern asylum nurse or attendant, as
contrasted with the old-time “keeper.” Devoid of sympathy,
brutalised by their surroundings, these latter were the very
worst class of persons to whom any of God’s afflicted creatures
could be entrusted. The asylum nurses of the present day are,
as a body, characterised by a humane disposition, reasonably
and sufficiently educated, competent, and sympathetic towards
their patients; their training is on the lines of that of a general
hospital, modified, of course, so as to meet the special demands
of asylum nursing, and altogether on a vastly higher plane than
was even dreamed of less than a century ago. They are,
therefore, well worthy of the kindest consideration, and the
comparatively small outlay involved in making their position
one of comfort and contentment is money well spent, and
probably in the end economical.

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In the discussion on Dr. Gettings’ paper on “ Dysentery
Carriers,” one or two points of interest were raised. Dr. Menzies
called attention to the necessity for distinguishing between
chronic cases of dysentery and actual dysentery carriers. “The
true dysentery carrier was the person who always had normal¬
looking stools and showed no symptoms of dysentery, either
during life or post-mortem. The chronic dysenteric case had
loose stools, either always or generally ; sometimes a little
mucus, and, rarely, blood.” He considered there was no
positive evidence as to the spread of this disease by carriers.
In this opinion the majority of the meeting seemed to agree.
There was not quite the same unanimity as regards the
usefulness of hyoscine in the treatment of the insane, which was
the subject of a short paper by Dr. Daniel. The outcome of
the discussion was to leave the impression that while in cases
of very acute mania it was often of signal benefit, it is a drug
which cannot be given for any length of time without producing
dangerous symptoms. The discussion on the Report of the
Status Committee was one of the most important and interesting
items on the programme. Criticism took mainly the shape of
doubts as to the feasibility of some of the proposals it embodied,
but on the whole the report met with the warm approval of
the members generally.

The entertainment of the members during their hours of
ease was well provided for. Grateful acknowledgments are due to
the President and Mrs. Thomson, who took the utmost pains
to make the meeting the success it undoubtedly was ; to the
Chairman and Committee of the County Asylum, who very
hospitably entertained the members to lunch; and to the Mayor
and Corporation for kindly placing the Guildhall at their
disposal for the holding of meetings. Dr. and Mrs. Thomson’s
At-Home on Tuesday, the 14th, was one of the pleasantest
incidents of the occasion. The weather, on the whole, was on
its good behaviour with the exception of Wednesday, the
central day of the meeting. On that day Dr. and Mrs. Rice
kindly invited the members to afternoon tea at the Norwich
City Asylum, which, owing to the persistent downpour, had to
be enjoyed indoors. Perhaps the most enjoyable episode
was the trip on the Broads on Thursday, the unique and
picturesque scenery of that part of East Anglia being quite a
new experience for the large majority of the party. The

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day was perfect, and it was an unalloyed pleasure to laze
at ease in a comfortable steam launch as it threaded its way
along the labyrinthine meanderings and lake-like expansions
of the river Bure. It happened that there was a regatta on
Wroxham Broads on the same day, which added to the interest
of the excursion. There was an ideal breeze for a yachtsman,
and there could hardly be a prettier sight than the various
units of the little white-winged fleet as they glided noiselessly
along the yielding surface of the reed-bordered expanse of
water. It was quite a merry party that sat down to lunch at
•the Swan Inn at Horning, brightened by the presence of several
lady friends, wives of members and others, and when the little
trip was over there was probably not one of the company who
shared in it who was not conscious of having had a delightful
■experience not easily to be forgotten.

Will it be considered ungracious to suggest the existence of
a fly in the amber? It is disappointing that, notwithstanding the
efforts made to render attractive these annual meetings of the
Association, such a comparatively small number attend. Out
of a total of 747 members on the roll, but 43 registered their
names as present, scarcely the odd number over 700, or about
5 per cent. Possibly many members, particularly our northern
colleagues, were reserving themselves for the impending, and
more imposing, meeting of the British Medical Association at
Aberdeen, with its opulent programme of both business and
pleasure.

As attendance at medical meetings for many days in
succession involves a good deal of mental strain, and convivial
gatherings considerable stress of another sort, many, no doubt,
did not feel inclined to face the double event. Still, it is
regrettable that so meagre a proportion of members found it
convenient to attend. As years pass on we must be prepared
to miss one after the other of the “ old familiar faces” of those
-who, for the past generation or more, have done their part in
keeping alight the torch of scientific psychology, and who have
helped to create and maintain the prestige of our Association.
Surely we may hope that a legion of worthy successors will be
■found to follow worthily in the footsteps of the old brigade,
to the inestimable benefit of those whose lives, and the lives of
those to whom they are dear, are clouded over by one of the
•most distressing calamities which can afflict humanity.

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The Advance of Psychiatry.

In the Revue de Psychiatrie for November, 1913, there
appears an article on Asylum Reform, by Dr. Toulouse, the
Physician-Superintendent of the Ville-Juif, Seine, Asylum.
Dr. Toulouse is well known for his persistent attempts to raise
the level of asylum work in the Department of the Seine, and
he has the conspicuous merit of saying, in plain words, which
steps are essential to that process. His statement of that
which remains to be done brings before us matters which are
familiar to us in this country. His cries and pleadings are
exactly those which our reformers have uttered, and are still
uttering. In our own British fashion, we, if not altogether
obsessed with pride when successful, are apt to be despondent,
and to refer to the better manner in which things are managed
in other countries. It is therefore somewhat reassuring to find
that, in some of the essentials, our endeavours have carried us
beyond the point at which the asylums of the Seine now stand.
Certainly this is the case when these asylums, the admissions
to which are drawn from the area where dwells the highest
centre of life in France, are compared with those interserving
the relative area in England.

Dr. Toulouse states as a cardinal fact that the cost, and the
consequences attached to the consideration of cost, are domi¬
nated by one most powerful prejudice—that insanity is incurable.
The chief interest of his article is to show the economic folly of
such an assumption.

The actual cost of asylum administration in the Department
of the Seine has increased 45 per cent, in the last ten years,
while the population has only increased by 13 percent. He
points out that this increase of expenditure has been almost
wholly devoted to the augmentation of the staff, and to
improvement in their wages. But the staff accommodation is
still below that which is considered proper for the ordinary
workman, and their hours are still too long, especially having
regard to their painful environment. But the cost of directly
ameliorating the condition of the patient, either in material or
therapeutic direction, has not generally increased. He tells
of over-crowding and want of classification, which latter in its
effect he terms barbarous, to be blushed for by generations to

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[Jan.,

come, and which eventually will be recognised as an important
factor of costly chronicity.

The acute cases are mixed with the chronics, with the
economic result that too much money is spent on the one class
and too little on the other. Hygiene is bad from over¬
crowding, lighting is by gas instead of electricity, and the
heating system inappropriate. The yards are small and view¬
less. There is no “ pare ” for exercise, and the means of
amusement and occupation are nearly non-existent.

The therapeutic machinery is yet in embryo. Hydrotherapy,
insolation, light, electricity, radiotherapy cannot be used in
suitable conditions. There is no central laboratory for making
biological researches.

Dr. Toulouse warns his authorities that the organisation of
the asylum is far from having reached a point at which any
reduction of expenses can be considered. He states plainly
that, though the General Council is always favourable and
generous towards progress, it has to consider the available
resources, and undertakes other charges which appear to it
to be more urgent. Dr. Toulouse considers it to be his strict
duty to let the Council know how the asylums can be, and
should be, administered. He thinks it necessary that it should
not be allowed to think for a moment that any great economies
can be practised without serious effects on the patients.
Improvement and progress must cost money, and call for
sacrifice. Comparison is made between the relative expenses
of treating insanity in asylums and of treating disease in
general hospitals ; the public seem to think there is less justi¬
fication for them in the former. The consciences of many are
troubled with the doubt whether the sacrifices made for the
asylums are of any avail, and it is such prejudice that must
be fought.

Dr. Toulouse argues thus: Each patient costs £44 per
annum, each discharge—recovered or improved—relieving the
department of that liability, which may go on for twenty
years or more in case of non-discharge. Any therapeutical
improvement costing ^400 will be covered if it aids in pro¬
curing the absence of ten patients for one year, or the absence
of one patient for ten years. One must always bear in
mind that patients are not put into asylums without any
hope of discharge. It is difficult to prove the influence of

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reforms on the discharge-rate, for the effect may not be
immediate, and results must depend on the material submitted
to treatment. Dr. Toulouse claims that in comparing asylums
with general hospitals (where there is but little haggling over
expenditure) it will be found that in the rate of recoveries
there is probably not much difference. In both, acute cases
get well—the maniac in the one, the typhoid in the other—
but when we come to consider the chronics, he says that the
results are heart-breaking in both cases. Does recovery arise
in the ataxies, the brain-softenings, the spinal-sclerosis ? What
about the diseases of other organs—the heart, the liver, the
kidneys, etc., which form the bulk of cases sent to hospital ?
Is confirmed tuberculosis or cancer cured at the hospital ?
We might suggest on our own part hysteria. Yet a patient
costs daily 5 francs in a hospital, an old person 2 fr. 50
in a hospital, 3 fr. in an asylum, and only 1 fr. 50 in the
asylum for chronic of Paris. The powers that be are always
ready to spend more in fighting tubercle, cancer, and infectious
diseases. Why then does the cost weigh more heavily on
conscience in respect of the insane ? Because sympathy is
removed from them. The insane man no longer exists
socially, while the others preserve always their influence and
their power to exercise their rights, civil and political. But
although certain physical maladies do not appear to yield
many cures, nevertheless medical research is continuously
supported in the hope that they will improve therapeutics. In
insanity it is thought that on the one hand the chronic cases have
acquired anatomical conditions which cannot be rectified, while,
on the other hand, the causes are wrapped up in obscurity so
as to defeat all medical analysis. Insanity, both chronic and
acute, appears to them to call for relief, and not for the doctor.

Nothing can be more false than such an idea. Dr. Toulouse
maintains that the anatomical disorder in simple psychoses is
not generally profound. As an indirect proof he refers to
spontaneous and rapid cures occurring in cases of quite old
standing, which do not occur in tabes, organic heart-disease,
etc. There are no decisive histological reasons which can of
themselves make one think it impossible to arrest, or even cause
regression in an anatomical lesion. We not infrequently see
this phenomenon, and we cannot say why it occurs ; that is all
that can be said. Are the processes of cure, like the aetiolo-

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gical processes, so obscure as to completely escape medical
analysis and action ? Nothing can be more inaccurate. Observa¬
tion of acute cases, and more especially of convalescents who can
express their impressions formed when ill, shows that the process
is simple. All Dr. Toulouse’s researches show that the con¬
fused type of acute insanity is a malady of fatigue, of physio¬
logical, and often of social, misery. It is an exhaustion
which each one can recognise in himself in moments of over¬
jadedness. “ Auto-conduction ” is weakened, and thought, in
the absence of direction, becomes automatic. The patients say
that they are not masters of their own ideas, which work without
ceasing, trouble sleep, drive them to acts and reasoning which
they judge to be absurd. The power to arrest, coerce, direct
them is failing, and effort is required to prevent the brain
foundering. Rest, produced by medical means, is required,
and may save the situation. He instances his own practice
of the substitution of bromide for salt in the diet, and he has
found the subcutaneous injection of oxygen to be very helpful.
Rapid recovery and general improvement demonstrate that the
physician can intervene successfully in acute psychopathy, so
often produced by exhaustion or toxins. Professor Charles
Richet, to whom Dr. Toulouse communicated his ideas of pro¬
longing sleep, produced by non-toxic means, during several
days, has suggested respiration in an hermetic chamber of
carbonic acid, which appears to have little danger about it.
Dr. Toulouse laments that the difficulties in providing his
asylum with such a chamber have not yet been surmounted.

Taking the above as an instance of the physician’s power
to intervene, he maintains that if there is a department of
disease in which such power can be used successfully it is that
of insanity, and, further, he maintains that it is fair neither to
the patients nor to scientific truth to regard the treatment of
the insane as a sort of costly Utopia, in which it is unwise to
encourage development.

Dr. Toulouse recites at some length the directions in which
he has personally striven to produce reform, and he also sets
out the lines on which such reform should be practised. With
these we are already familiar from the work that has been
proposed, thought out, and in many cases carried through in
our own country. Dr. Toulouse, no doubt, approving the
system of Alt Scherbitz, would have in the neighbourhood of

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Paris an immense asylum-town for 5000, or even 10,000,
patients.

He concludes his excellent paper with the contention that
the asylum should not be a field for experiments in economies,
but, on the contrary, that the physician there, as elsewhere,
should have a free hand in procuring reform and improvement.

The line of argument adopted by Dr. Toulouse, with which
we were not unacquainted, is undoubtedly a sound one. Every
thoughtful man will concede that the effort to disarm insanity
is worth a vast amount of expenditure on the part of a nation,
while an increasing recognition of insanity as a disease requiring
the utmost benevolence per se tends to increase the readiness to
spend money on its treatment. Still, there is a prevailing
obsession that the prospect of real amelioration is so slight
that money so spent is so much waste. Thus we start with
much reluctance to make a determined attempt at amelioration,
and what is done is done more by way of satisfying obvious
requirements, due to increasing benevolence, than for the
purpose of experimental scientific progress. As psychiatrists
we may well ask why insanity is left behind when so much
forward endeavour is made in general medicine.

It is part of the tragedy of the war, which has been so ruth¬
lessly thrust upon us, that it has come just at a time when it
was hoped that some serious consideration might be paid to
our pleas for psychiatrical advance. It cannot be doubted that
this and many other similar movements must be arrested
during the period of national recuperation. But we feel con¬
fident that when wrong is subdued, and right prevails, a time
of peaceful progress is in store for the nations of Europe.
Until that time, however long, comes we may regard the
Report of the Committee re Status of British Psychiatry as
embodying views which will remain virile. Further, we may
consider ourselves fortunate that this Report was finished and
adopted just in time to escape the present disorganisation of
the national life.

The War—Treatment of Alien Enemies in a Concentration

Camp.

We have received from Professor L. Brauer, Medical
Director of the Eppendorf Hospital, Hamburg, an open letter

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on the treatment of German Aliens at the Prisoners of War
Camp, Newbury, also on the question of the war generally.
It is signed by Professors Brauer, Dencke, Nocht, Rumpel,
Simmonds, and Drs. Marben, Mann, and CEhrens.

The letter conveys nothing further than similar letters from
German savants, published from time to time, have done, and
there is nothing to be gained by its reproduction here.

Regarding Newbury Camp—now abolished—it is admitted
that, at first, conditions were very crude, but the prisoners soon
settled down and the happiest of relationships, considering the
circumstances, were soon established.

We have had access, through the courtesy of the War
Office, to the reports of the Commandant, Colonel Haines, and
there is a u,, ndant testimony that the great majority of the
prisoners were grateful for the considerate treatment they
received, and have not hesitated both publicly and in private
letters to express themselves so.

The majority of the charges made in the open letter are
either untrue, exaggerated, or unfair. No allowance is made
for the unpreparedness for the accommodation of large numbers
of prisoners of war, and for the prevailing unfavourable weather,
and we are satisfied that all was done that could be done to
secure comfort under difficult and unexpected circumstances.

We congratulate Colonel Haines on his excellent manage¬
ment, of which there is such adequate testimony.

As regards the rest of the letter, we have complete confidence
that when the time comes for the analytical and dispassionate
consideration of all the circumstances that led up to the declara¬
tion of war, and the attitude and behaviour of the British people
since, the signatories of the letter under review will have good
reason to regret that they have allowed their better judgment
and common-sense to be influenced by people whose implacable
hatred of England is only equalled by their utter disregard for
truth and right dealing, and whose noisy interference is rapidly
driving a war waged in defence of principles, however irrecon¬
cilable, into a racial conflict which can only end in the extermi¬
nation of one side or the other.

We are confident that we fight in a noble cause, and in our
ability to succeed, and equally confident that our German
colleagues, in the peace to come, will, after calm reflection,
recognise that right was with us.

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Part II.—Reviews.

Sixty-third Report of the Inspectors of Lunatics (Ireland), for the Year
ending December 3 1st, 1913.

That the tide of lunacy in Ireland continues on the ebb is again an
inference deducible from the statistical facts given by the Inspectors in
their latest Report. When reviewing that of last year (1912) we drew
this conclusion, quite a warrantable one, we believe, from an examina¬
tion of the figures for the six most recent quinquennia, from which
it appeared that the percentage rate of increase in the proportion of
insane under care per 10,000 of population was, for each five-year period
after the first, i 8'4, 16 2, 177, 115 ( ] ), and 5 - i respectively. If we
bring our calculations up to date, and compare a similar number of
five-year periods terminating with 1913, the record is still more favour¬
able, the corresponding ratios being 18 2, 17 0, 16 8, 97, and 4 8.
Such figures carry an unmistakable meaning—the tendency of insanity
in Ireland to increase is decidedly on the decline for the past ten years.
This downward tendency is progressive, not fluctuating ; and the fact
that the actual increase in numbers in 1913 was 100 less than the
average increase for the ten years preceding may be regarded as corro¬
borative evidence.

As regards first admissions also, admittedly the real criterion of the
increase of occurring insanity, computations of quinquennial averages of
ratios to population show further improvement as compared with those
available up to the close of 1912. The percentage increments in the pro¬
portion per 100,000 of estimated population for the first four of the five
quinquennia ending with that year were ir6, 9 2, j 7"3, and 5'3 respec¬
tively, while in the last quinquennium there was an actual decrease of
1*4; for a similar series ending 1913 tire percentage increases for the
first four periods were 137, 8*5, i9 - o, and 1*2, and in the last quin¬
quennium a positive decrease of 4^4 per cent. In the face of these
figures, it can hardly be maintained that the prospect of a term being
at last reached in the progressive march of insanity in Ireland is other
than reassuring, and there are substantial grounds for hopefulness as
regards the future. This is the one salient fact disclosed by statistics,
and deserves to be put in the forefront in any comments thereon.

The total number of insane under care on January 1st, 1914, was
25,009, showing an increase of 170 during the year, which was, as
already stated, 100 less than the average increase for the last ten years,
a significant fact in itself, the main increase having, of course, been in
district asylums, which accounted for 156 of the total. There was an
increase of 6 in private asylums, of 4 in Dundrum Criminal Asylum, of
1 in workhouses, and the balance of 3 were cases of single patients in
unlicensed houses. Of the total under care 5 per cent, were in private
asylums, 10 per cent, in workhouses, and 85 fer cent, in district asylums.

The recovery rate in district asylums was 39' 2 per cent, on admissions,
which was well up to the average of a large number of years past.

. Table VII of Appendix B is a most useful one, as it gives the average

(') Entered as to‘6 by error in last year’s review.

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percentage of recoveries and deaths extended over a series of years
divided into five-year periods, so that it can be seen at a glance whether
there is an increase or a decrease in the ratios recorded. And, perhaps,
the most remarkable fact disclosed by this table is the practical uni¬
formity of both recovery-rate and death-rate. During the past twenty
years, great advances have been made in our knowledge of insinity,
great advances also in the more scientific treatment of the malady, and
in the many additional comforts and amenities which are now provided
for the insane, influences which might be expected to react beneficially
on the recipients, and tend to raise the recovery-rate generally. And
yet the hard, unwelcome, shall we say (to psychiatrists) humiliating, fact
remains that as regards the recovery of insane patients there cannot be
said to be any improvement whatever. It continues to be practically
identical with what it was twenty years ago. To find a satisfactory
explanation of this circumstance is, no doubt, difficult, if not impossible.
There is room, however, for suggestions, of which we venture to
advance one, while fully conscious of its inadequacy. A number of
cases of insanity—a minority, it is to be feared, and not a large one—
do appear to completely recover, and never have a second attack. The
larger number have a tendency to recur, and, after a certain number of
recurrences, to become chronic and incurable; these form the bulk of
our asylum population. It is probable that in the more favourable
cases there is little or no hereditary tendency, whereas, in those which
form the majority, heredity acts largely as a predisposing cause, and
also as largely as a hindrance to ultimate complete recovery. Now, it is
not unlikely that the relative proportion of these two classes of insane
does not vary to any great extent in any age or generation. Nor can
treatment, however scientific, be said to be of avail in preventing
recurrence, and, in the end, chronicity. Treatment in the case of acute
attacks has, we have reason to believe, very beneficial results, and aids
to more speedy recovery ; but its effect in the unfavourable class alluded
to has no element of permanency, and the insanity will recur again and
again in spite of any remedial measures employed. Like nature in the
Horatian adage, you may drive it out with a pitchfork, but it is always
bound to come back. Consequently, while Restitution to the normal
is probably greatly aided and expedited in cases of acute insanity by
modern methods of treatment, the general recovery-rate, as revealed by
statistics, has shown no improvement, nor is it likely to, until we
succeed in discovering and applying the means not merely of cure, but
of the prevention of insanity.

Insanity is a subject which can be regarded from multiple stand¬
point^, and it is of advantage at times to concentrate attention upon
some one of these, and deal with it more exhaustively than is usual. In
their penultimate report the Inspectors discussed at some length the
question of the relationship of the distribution of insanity to certain
possible aetiological factors, such as density of population, pauperism,
emigration, and alcoholism. The local distribution of insanity, and its
progressive increase during the past fifty years, were given a prominent
place in last year’s report, and in that of this year the subject of age
distribution, and its bearing on insanity, is more particularly investi¬
gated.

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The report deals with the half-century 1861-1911. During these
fifty years the population of Ireland fell from 5,798,967 to 4,390,219.
This is attributed mainly to emigration, aided in recent years by a
decreasing birth-rate. During this period the age-distribution has
undergone a material change, the proportion of population under twenty
years of age having fallen from 44^4 to 39‘3 per cent.; while that at
sixty-five and over has risen from 47 to 10 per cent., the decrease in
the ratio of the youthful portion of the population being thus almost
identical with that of the increase of senility, while the ratio of persons
aged twenty to sixty-four is practically the same in 1911 as it was in
1861. But from the fact that the proportion of persons aged forty-four
to sixty four increased from i6'9 per cent, in 1861 to i7‘i in 1901, while
it fell to i5‘4 per cent, in 1911, the conclusion is drawn that it is
probable that a maximum of senility has been reached.

As regards the incidence of insanity at the several age-periods, we
find from the census reports that the proportion of cases under twenty
decreased during the fifty years under review from i5‘6 to 4'8 per cent.,
while that of senile cases (sixty-five and over) increased from 6^4 to 14
per cent. There was a slight increase in the ratio of cases between the
ages of twenty and sixty-four, viz., from 78 to 812 per cent. The chart
giving these proportions in graphic form enables us to see these differ¬
ences at a glance. And they are of great significance. In the case of
the aged we must always expect a certain number to be the subjects of
mental breakdown, and, although this is regrettable when it occurs, it
is by no means as lamentable an event as a similar occurrence in the
young. And it is a matter deserving of the highest congratulation that
the incidence of insanity in the case of the younger members of the
population has been so largely reduced. It is one of the most hopeful
facts revealed in the recent records of insanity.

The proportion of insane and idiots per 1,000 of population, as given
in Table C, also shows the same facts, although not, perhaps, in quite
so st 1 iking a manner as regards the younger ages. The ratio of these
(under twenty) per 1,000 is a merely fractional figure, but fell from 0 85
to 079 during the fifty years, while that of the senile cases (over sixty-
five) rose from 3^3 to 9 per 1,000. The rate of increase in the ratio of
cases of twenty-five to forty-four and forty-five to sixty-four was veiy
different, that of the former class having risen from 37 to 8 4, and of
the latter from 37 to i4’9 per 1,000, showing again the influence of
senility.

The large increase in the number of senile persons in the population,
which, as already mentioned, exactly corresponds with the decrease in
the case of those of youthful age, is. no doubt, mainly due to emigra¬
tion, and the increase in insanity is probably explicable, as the Inspec¬
tors suggest, on the grounds that this class “represents the senility of a
period when the population of Ireland was much larger than at present.”
And, further, that as probably a large number of aged persons who have
become insane during the past twenty years were alive during the
famine years, when dire distress prevailed throughout the country, it is
hardly to be doubted that such a time of stress and misery would be
likely to have had a deleterious effect on the young people of that time,
and, through maternal influences, even on those who were yet unborn.

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And there seems no reason why we should not accept the Inspectors’
surmise that “ it seems probable that children born and partially reared
amidst the horrors of the famine, and the epidemics of disease that
followed it, were so handicapped in their nervous equipment as to be
weak-minded from the start, or to fall victims to mental disease later.”
And we welcome the conclusion that “ if this be so, there is hope that
the insanity-rate may have reached its maximum rapidity of increase.”

In the table on page xxvi we should like to see an extra column,
giving the percentages of total mortality of the three causes of death—
phthisis, general paralysis, and epilepsy—for five-year periods. This
would add materially to its usefulness. In this table the records for
four such periods, commencing with 1890, are given, and for four years
ending with 1913. The present year will complete the fifth quinquen¬
nium, and would, therefore, be an appropriate starting-point for the
additional item pf information suggested.

The general tenor of the report is of a more cheering character than
has yet been evident in any of those which have preceded it.

Nature and Nurture in Mental Development. By F. W. Mott, M.D.,
F.R.S., F.R.C.P.Lond., LL.D.Edin. With 6 plates and 17 figures.
Pp. 151. Crown 8vo. Price 35. 6 d. net. London: John Murray,
1914.

“This book is an expansion of the Chadwick Public Trust Lectures, delivered
by Dr. Mott in 1913, in which the author expounded the subject of ‘ Mental
Hygiene ’ in relation to the inborn characters of the child and its environment.
The subject is first considered from the physiological and anatomical standpoint
of the brain specialist and leads up to the explanation of the factors underlying the
raw material of character and how this is influenced for good or bad by ancestral
inheritance. The complexus of characters derived from species, race, sex, and
ancestors is dealt with. A large practical experience has enabled the author to
treat of the subjects of responsibility, crime, mental deficiency, and insanity, and
how they are affected respectively by inborn and environmental conditions of
social life. Lastly the author discusses the influence of nutrition and education in
relation to the development of body and mind in their medical and social aspects.
The subject is simplified to the lay reader by the reproduction of various illustra¬
tions, diagrams, and pedigree charts, which were used at the lectures.”—( Pub¬
lisher's Announcement.)

This work, in fact, conveys in shortened, but wonderfully complete,
form the author’s well-known scientific opinions and investigations, as
far as they bear on the important sociological problem of the influence
of nature and nurture in mental development. Information from other
equally reliable sources is given, criticised, and adopted or rejected.

Its pages are full of sage counsel and condensed wisdom, and ought
to be read widely, especially by those in a position to influence the
future of the race. No better guide could be placed in the hands of
school teachers, and others interested in education. It is written in
language at once subdued, simple and weighty, conveying conviction to
the mind of the reader that the author is one who can speak authori¬
tatively on the subject.

The book opens with a short account of the progress of sanitary
science. After commenting on the three stages, viz., the growth of

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industiialism, social reform, and the naturalisation of education, the
author betrays a commendable optimism. He says:

" Each of these stages has supplemented and reinforced the other; yet we hear
on all sides the pessimistic cry of the degeneration of the race set up by a few
unthinking people who advocate a laissez-faire, or the so called ‘better dead,'
theory of all those who are unable, through inborn lack of vitality, to resist racial
diseases. Are we to listen to these pessimists? No 1 Rather should we look with
pride to what has been done in the last fifty years to better the conditions of the
people."

Facts follow which support his contention.

The anatomical and physiological aspects of the brain and mind are
sketched with a masterly hand. It is refreshing, in these days of verbosity
and involved reasoning, to read such succinct passages as :

“ All nervous action is reflex, and the simplest reflex act is the first term of a
series, of which the most complex volition is the last.” “ Although the brain is
the organ which stores the recollection of past experiences and the bonds that
unite them, thereby enabling the individual to adapt himself to environment, yet,
strictly speaking, the mind is directly dependent upon the vital activities and
harmonious interactions of all the organs and tissues of the body ; for of what use
would the brain be without the peripheral sense organs and the nerves which
connect them with the spinal cord and brain ?”

Or,

" But another fundamental function of the brain besides perception of the
external world and its surroundings is the consciousness of the individual’s own
personality, his appetites and desires, which are due in great part to the organic
sensibility of the nerves of the body and internal organs, which without cessation
are continually carrying messages to the brain, making us aware of our existence
and our needs.”

Again,

“ It is the consciousness of feelings connected with the preservation of the
individual and the preservation of the species which constitutes the fundamental
biological source of all vital activity.”

And,

** The mental states concerned with the consciousness of appetites and desires
and the control of the instincts and habits associated with their gratification, the
avoidance of pain and the obtaining of pleasure essential for the preservation
of the life of the individual and reproduction are the mainspring of human
activities, passions, and emotions."

As regards the biological basis of heredity, Dr. Mott quotes Lucretius
and says:

“ Of the broad principles of human heredity we know very little more than this
ancient philosopher—science, aided by the microscope, has taught us much con¬
cerning the material basis of inheritance; it has shown that plants and animals are
reproduced on the same common plan of a dual inheritance from the male and
female germs.”

Discussing the much-debated question of the transmission of acquired
characters our author thus expresses himself:

" The majority of biologists deny the possibility of the transmission of an
acquired character, and I would agree up to a certain point that there is no
evidence or proof that an acquired character can be transmitted. That a father
who drinks heavily and sees his wife and family starving transmits the desire to
drink in his offspring is illogical and unproven; but he may transmit that inborn
character which will lead to his offspring drinking, vis., lack of moral sense and

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feeble will." " If the devitalising agency caused by a poisoned condition of the
blood is carried on in several successive generations, and especially if reinforced by
a similar loss of specific energy in the female germ from similar and other causes,
weakly types of offspring will be produced, etc.”

Dealing with the question of the sources of degeneracy, and the effect
of the interference of medical science, legislation, etc., with natural selec¬
tion and the survival of the fittest, Dr. Mott describes how weakly types
are cut off early by invading microbes and the antedating of heritable
disease, and how essential a healthy bio chemistry is to a healthy mind.
The remedy to degeneracy is clearly put:

" Now, a healthy mind can only exist in a healthy body, and the proper storage
of mind energy; its liberation, as well as recuperation (all necessary for a well-
balanced mind), are largely dependent upon an inherited good and virile constitu¬
tion ; whereas the higher functions of the mind on the side of feeling, via.,
imagination and the affective nature, are specifically inherited, and more depen¬
dent upon inborn variation from the normal average mind.”

The problems of heredity in relation to character, genius, and crime,
the weeding out of poor types, the neuropathic inheritance are more
fully discussed in later sections, and illustrated by many interesting
pedigrees.

Regarding genius, which so often occurs in neuropathic family trees,
and the loss the world would have sustained if the existence of these
families had been prevented, Dr. Mott says :

“ Still, if a nation, in order to progress, must have an admixture of mental insta¬
bility in the form of imaginative genius and insanity, a thin streak of it is
sufficient; for that nation will be the most virile which can breed from the greatest
number of individuals endowed with the attributes of civic worth, courage, honesty,
and common-sense.”

Another striking paragraph is :

“ An unsound stock may have successful men in the eyes of the world, but
these may really form the first step in the process of degeneration ; for the avarice
and moral guile which made them ‘ pillars of society ’ may come out in the next
generation as gross criminality or insanity.”

How true this is we all know. Sections devoted to sex in relation to
character, crime, and insanity form interesting reading. Dr. Mott is no
advocate of the suppression of the legitimate exercise of the sexual
functions in either sex. Would that his healthy words could reach the
all too numerous and narrow minded crowd of worthies to whom the
sexual aspect of life is anathema.

With regard to racial inheritance and crime, Dr. Mott has little
sympathy with the teachings of Lombroso :

“ But Calibans are not common ; and Lombroso's inborn types are limited to a
small group of markedly degenerate criminals closely approaching the feeble¬
minded.”

Having thus, as it were, dealt with the origin of the racial unit, our
author devotes himself to the more practical side of the question, and
succeeding sections are devoted to such all-important matters as nutri¬
tion in mental development, the health of the mother in relation to the
child, parental disease, infant feeding, education, stimulus in relation to
development of the brain, sleep, the health of the teacher, etc.

It is impossible to deal with all these aspects of the subject in a

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limited review. Two points may, however, be mentioned. Dr. Mott
very rightly thinks that the medical inspection of the teachers is only
second in importance to the medical inspection of the children. He
urges the necessity of adequate remuneration, and the limitation of hours
of labour, to enable teachers to enjoy normal, restful, and recreative,
personal and social life. He points out that the ill-paid, and therefore
ill-nourished, worried, tired drudge can have no joie de vivre to reflect to
the child. His words should sink deep into the minds of some county
authorities.

He speaks strongly on the much-debated question of sex and
education :

“ Without instruction, youths and maidens may grope their way to knowledge
in semi-darkness under dangerous social conditions, against which they ought to
be forewarned by instruction."

He thinks that suitable information on sex matters should be imparted
to boys and girls just before leaving school by men and women espe¬
cially chosen on account of their knowledge, wisdom, and high moral
character. He adds that it might be well to invite parents to be present
at these lectures. We, on our part, think so too on other grounds, for
the remarkable ignorance of many parents is scarcely removed from that
of the children, and the moral and material atmosphere of many a home
would be sweetened and rendered more wholesome by a little sound sex
education of the parents.

As an appendix is an important report by Miss Agnes Mott on the
medical inspection of school children, for which she is to be much
commended.

Part III—Epitome of Current Literature.

1. Physiological Psychology.

The History of the Psycho-analytic Movement. [Zur Geschichte der
Psychoanalytischen Bewegung\. ( fahrb. d. Psychoanaly ., 1914.)

Freud, S.

In the psycho analytic movement history has been made rapidly, and
amid the various revolutionary currents it must be difficult even for the
prime leader himself to know exactly where the movement stands. In
this characteristic and interesting paper, he seeks to show where he
himself stands. He imparts an autobiographical value to the narrative
by carrying it back to the days of his early medical life in Paris. He
had become a doctor unwillingly, but was anxious to benefit neurotic
patients, and thought that this could be done by the exclusively physical
methods of electro-therapy.

The doctrine of suppression and resistance was one of the first
elements of psycho-analysis to become clear to Freud, and he regarded
it as an original discovery until he found it set forth by Schopenhauer;
“ it is the foundation stone on which the edifice of psycho-analysis rests.’
That theory, he declares, is an attempt to make intelligible two man:

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Testations always found when we seek to trace neurotic symptoms to their
source : the fact of transference and that of resistance. “ All investiga¬
tion which recognises these two facts, and makes them the point of
departure is psycho-analysis, even when it leads to other results than
mine.” He strongly objects, at the same time, to suppression and
resistance being termed “ assumptions of psycho-analysis ”; they are
results.

The doctrine of infantile sexuality was a somewhat later acquisition.
It had turned out that the events, to which the hysterical symptoms
were traced back, were imaginary scenes in many cases. It soon became
clear that these scenes had been imagined in order to conceal the auto¬
erotic activity of early childhood, and behind these imaginations the
sexual life of the child becomes revealed in all its extent. Herewith inborn
constitution came into its rights; predisposition and experience were
woven into one inseparable astiologic unity, each element being ineffec¬
tive without the other, and the child’s sexual constitution provoking
events of an equally special kind. Freud can understand that other
views of the sexual impulse in relation to childhood may be put
forward, like those of C. G. Jung, but regards them as capricious,
formed with too great a regard for considerations that lie outside the
subject, and so remaining inadequate.

Freud states that he found out the symbolism of dreams for himself
(“ I have always held fast to the custom of studying things before I
looked into books ”), and only afterwards found out that Schemer had in
some degree preceded him, while later he extended his view under the
influence of “ the at first so estimable, and afterwards wholly abandoned,
Stekel.” He adds : “ The most peculiar and significant fragment of my
dream theory is the reduction of the dream-representation to inner
conflict, a kind of intimate insincerity,” and this idea he has also found
in the writings of J. Popper. As is known, Freud attaches immense
importance to his doctrine of dream interpretation, and he remarks that
he is accustomed to measure the competence of a psychological
investigator by his relation to this problem.

At first Freud failed to realise what the attitude of the world would
be towards his doctrines ; he thought they were merely contributions to
science, like any others. By the atmosphere of cold emptiness speedily
raised around him he was soon made to feel that medical communica¬
tions introducing sexuality as an retiological factor were not as other
medical communications. He found that he had become one of those
who, in the poet’s words, “disturb the world’s sleep.”

A considerable part of this lengthy paper is a criticism of Jung and of
Adler, too full of matter to be easily condensed. He is not inclined to
rate highly Jung’s conception of the “ complex,” as involving no psycho¬
logical theory in itself, nor yet capable of natural insertion into the
psycho-analytic theory. Moreover, no word has been so much abused,
and it is frequently employed when it would be more correct to use
“suppression” or “resistance.”

Of Adler, Freud speaks with respect as “ a significant investigator,
more especially endowed for speculation,” whose studies of the psychic
bearing of organic defect are valuable, and whom he had placed in a posi¬
tion of high responsibility in the psycho analytic movement. But that

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theory was never meant to be “a complete theory of the human psychic
life,” but only to enlarge or correct what experience had otherwise
gained. Adler goes far beyond this, and attempts to apply to the whole
character and behaviour of mankind the key intended for its neurotic
and psychotic perversions. Freud admits that “Adler’s efforts for a
place in the sun ” have had their good results, but his “ individual psycho¬
logy ” is now outside, and even hostile to, psycho-analysis. Freud pro¬
ceeds to criticise forcibly the extreme emphasis which Adler places on
“ masculine protest ” and on the impulse of aggression. “ He leaves no
place for love. One may wonder that so sad a view of the world has
found any recognition; but we must remember that humanity,
oppressed by the yoke of its sexual needs, will accept anything if only it
is offered with the bait of a conquest over sexuality.” Freud is, how¬
ever, much more favourable to Adler than to Jung. Adler’s doctrine he
regards as, indeed, radically false, but he possesses significance and
coherence. Jung’s modifications of psycho-analysis, on the other hand,
are confused and obscure; he has changed the handle of the psycho¬
analytic instrument, and also put in a new blade, so that it is no longer
entitled to bear the same mark.

Freud observes of his paper that it will cause glee to many to find the
psycho-analysts rending each other. But similar differences and diffi¬
culties, he points out, occur in all scientific movements. “ Perhaps they
are usually more carefully concealed; psycho-analysis, which has
destroyed so many conventional ideals, is in this matter also more
sincere.” Havelock Ellis.

An Experimental Study of Stuttering. ( Arner . Journ. PsycholApril,
1914.) Fletcher , J. M.

Although stuttering has been known to medicine, the author remarks,
since the days of the ancient Egyptians, there is still no consensus of
opinion as to its nature. He attempts in this fairly elaborate study to
approach it from the standpoint of psychological laboratory methods,
and to offer a psychological interpretation, though not of the same kind
as that put forward by the Freudians, which he opposes. In setting
forth his interpretation he admits the probability that a favouring neuro¬
pathic diathesis is present in the stutterer.

The motor manifestations of stuttering are found to consist of
asynergies in the functioning of the three musculatures of speech—
breathing, vocalisation, and articulation. With these are involved motor
anomalies, tonic and clonic, of other muscles, and tending to become
stereotyped. It is especially in the accessory movements that stutterers
differ widely. Besides the motor manifestations, there are disturbances
of pulse-rate, blood distribution, and psycho-galvanic variation, varying
approximately in intensity with the intensity of the stuttering. The
essential condition is a complex state of mind, to be classed generically
as a state of feeling in the wider sense. It is quality of feeling, however,
rather than intensity, which governs the defect. In over 50 per cent, of
cases speaking in public caused disappearance of stuttering. Peelings
of inhibition or depression (fear, anxiety, shame, embarrassment) are
those most likely to precede stuttering. The quality of mental imagery,
attention, and association also seem influential. The emotional con-

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comitant, much more than the nature of the sounds, determines the rise
of stuttering. It is, therefore, “essentially a mental phenomenon in
the sense that it is due to and dependent upon certain variations in
mental state.” A lengthy bibliography is appended, with numerous
plates of tracings. Havelock Ellis.

The Tele algesic Hallucination [/.’ Hallucination Te!ealgtsique\ ( L'Ence -
phale, May , 1914.) Courbon.

The painful sensation following on the perception of a gesture
executed by another person, and localised in the part of the body
towards which that gesture was directed, is a phenomenon which may
take on various forms. Its explanation depends on the probability that
there is a special neuro-cerebral apparatus for the exercise of the
function of the differentiated form of sensation which we term “pain ”
—the algesic function. Hallucinations of pain have for a long time
been described. Courbon believes that he is the first to describe
painful hallucinations, provoked by another person, and varying in locality,
at the will of that other person. The case he presents is that of an
ignorant and unintelligent servant, a woman, aet. 59. Since the age of
thirty she had suffered from shifting pains, which various doctors had
diagnosed as due to a disordered stomach. At the age of fifty the pains
began to be accompanied by a vague fear. A few years later she began
to think that her pains and her fears had a cause; people wished her ill,
and wanted to kill her. At night she seemed to see men with knives,
no doubt the people who were inflicting the pains upon her. This
vaguely systematised idea of persecution led to her removal to the
asylum. Here it was found that any gesture of a bystander accidentally
directed towards her, or even ordinary movements of a bystander, such
as blowing the nose, led to pains in the corresponding parts of the
patient’s body; she regarded all such movements as intended to injure
her. The condition remained unchanged when the patient, who had
been voluntarily placed in the asylum, was taken away eighteen months
later.

These are genuine hallucinations, Courbon concludes, though of a
special kind. They belong to the category termed by Kahlbaum “ reflex
hallucinations,” and by Regis “ transposed hallucinations.” In a slight
and normal degree sensitive persons have similar experiences at the
theatre. In this extreme and morbid form the hallucination is the
apparent realisation of the subject of the malevolent intention attributed
to the other person’s gesture. It is the transformation into sensation
of a false idea. It is, therefore, a hallucination determined by a
delusional interpretation. Havelock Ellis.

Factors in the Physiology of Euphoria. (Psychol. Rev., May, 1914.)
Dearborn, J. V. N.

The experience of satisfaction or pleasantness, called euphoria, is
regarded, following Herbert Spencer, Marshall, and others, as due to
the ample, unimpeded, and expanding nervous impulses received from
large nervous fields. The author considers it is possible to be more
explicit regarding some of these fields. He deals mainly with physio-

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logical euphoria, not with ideational euphoria, or that pathological form
found in insanity.

The factors he takes into consideration are (1) nutritional and sym¬
pathetic influences from the active intestinal villi, probably adapting
the blood’s content of lipoids and protein to the varying immediate
needs of the nerve-cells; (2) kinesthesia proper, that is, the tonus and
active contraction of the voluntary musculature (including articular,
osseous, etc., fields) contributing to the dynamic reservoir of the central
nervous system, or cerebral neurokinesis; (3) epicritic or dermal
impulses, of great importance and including many complex mechanisms
in the skin and mucosa:. Physiologic euphoria is thus determined by
simple neurokinesis, and such neurokinesis is the condition for the high
sthenia necessary to actuate or inhibit vigorously the motor paths.

Havelock Ellis.

The Reaction of the Circulation to Psychic Processes [ Ueber die Normale
und Pathologische Reaktion des Blutkreislaufs auf psychische
Vorgdnge]. (Neurolog . Centralbl., fan. 16th , 1914.) Picket, H.

Bickel has made about a thousand observations on nearly eighty
persons, in health and in disease (psychoses and neuroses), in order to
ascertain the behaviour of the blood pressure on the plethysmographic
volume-curve under psychic stimulation, especially mental work,
intellectual pleasure and displeasure, sensory satisfaction and dissatis¬
faction, and attention. For the continuous observation of the oscilla¬
tions of blood pressure he used UskofiPs sphygmo-tonograph.

The blood pressure, whenever changed at all, was found, alike under
normal and pathological conditions, to be increased by these stimuli,
especially attention and pleasurable excitation. This increased pressure
could not be due to increased arterial tone alone, but also indicated
increased cardiac activity. The volume-curve (as other investigators
have previously found) behaved differently under normal and under
pathological conditions. In normal subjects (except for pleasurable
stimuli) the volume of the arm and ear sank, that of the brain and
abdomen rose; the blood would appear, with rise of the general pres¬
sure, to be transferred from the exterior to the interior of the body. In
the pathological subjects, on the other hand, the normal vaso-constrictor
innervation from the cortex to the exterior parts of the body is partly or
entirely broken ; instead of decrease of volume at the surface, there is,
especially with mental work, increase. The abdominal phenomena are
less clear, as the passive distension due to increased pressure is
counteracted by an antagonistic narrowing due to greater expansion at
the surface. Havelock Ellis.

Coenesthopathia \_Les Cenesthopathies\ (L’Encephale, May, 1914.)

Austregesilo and Esposel.

As ccenesthesia stands for the consciousness of the physical self, so
coenesthopathia is the corresponding psycho-neurotic syndrome, repre¬
senting morbid perversion of that consciousness. Normally, the
message from body to brain attracts little attention ; in neurotic and
psychotic conditions generally these sensations become more or less

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prominent and tinged with anxiety, but not usually to a degree consti¬
tuting ccenesthopathia. This is only reached when the symptoms
generally are found to revolve round the coenesthesia.

The authors accept the division of troubles of coenesthesia into (i)
hypermnesthesia, or feeling of exaggerated typical well-being common in
general paralysis and sometimes in mania ; (2) hypoccenesthesia ; and (3)
acccnes/ltesia, the diminution or abolition of euphoria found in hypo¬
chondriasis and sometimes in melancholia ; (4) paracaenesthesia , the
most frequent and variable group because it includes all the transfor¬
mations of physical personality, zoopathias, demonpathias, etc., as
found in alcoholism, dementia prrecox, etc.

Coenesthopathic changes have great symptomatic importance, as they
sometimes play the chief part in a neurosis or psychosis, although they
may also constitute an isolated syndrome. The latter part they most
frequently play in women, especially from puberty to the menopause,
when they become enormously frequent. They also become exaggerated
at the menstrual period.

Coenesthopathic troubles are more often found in great cities than in
the country, and some races, like the Latin and Jewish, are specially
liable to them. Chronic infections and intoxications in general, heredi
tory taints and over-strain, favour their appearance.

The ccenesthopathias are mostly cephalic and, especially, abdominal.
They constitute the basis on which other pathological manifestations of
emotional, ideational, or motor order rest. Formerly the patients were
regarded as neurasthenic, hysterical, obsessional, or hyponchondriacal,
and this indicates the task of differential diagnosis. On the psychiatric
side it is necessary to eliminate chronic hallucinatory conditions. We
are concerned with patients of tainted heredity, and constitutional lack
of balance ; the sensibility is abnormal, but there are no delusions.

Seven cases are presented. The treatment chiefly relied on is
psycho-therapeutical, and must sometimes be patiently prolonged.

Havelock Ellis.

Hypnotism. {Dub. Journ. Med. Set., April , 1914.) Stnyly, Cecil P.

In the most ancient times it was known that the phenomena now
called hypnotism could be produced, and also what conditions were
most favourable for their production.

Both in Egypt and in Greece the priests, who in those days were also
physicians, were skilled in the art of suggestion as applied not only to
the treatment of disease, but also to the production of so-called miracles ;
in Asia, especially India, hypnotism has been known and practised since
time immemorial, and is still in common use ; in less civilised com¬
munities the witch-doctor and faith-healer owe most of their success to
similar practices.

On the basis of astrology, which taught the influence of the stars on
the minds and actions of men, Paracelsus, about the year 1530, founded
the theory that men could influence one another, and especially those
who were sick.

In 1665, a Scotchman called Maxwell produced a regular system
of magnetic healing. He taught that there was a universal spiritus
vitalis which pervaded and acted on all living bodies, in a manner

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EPITOME.

[Jan.,

brass ; the ends were brought to a point, and were applied to the patient
by drawing the points in a downward direction over the afflicted parts
for twenty minutes.” These were the once famous metallic tractors.
In 1804, his son established the Perkinian Institute in London, under
the presidency of Lord Rivers. Dr. Haygarth, of Bath, however, found
the same good results were obtained by using tractors made of lead,
wood, or even a nail covered with sealing-wax.

In 1837, John Elliotson began to mesmerise patients at University
College Hospital, with the result that he was compelled to resign his
appointments. In 1843, he and his friends started a paper called the
Zoist, through the influence of which mesmeric infirmaries were opened
in London, Edinburgh, and elsewhere. In Exeter, Mr. Parker, a
surgeon, performed 200 painless surgical operations on mesmerised
patients. Among the cases reported in the Zoist were amputations of
the thigh, leg, arm, breast, etc., in addition to the cure of numerous
diseases.

In 1845, James Esdaile, having read of Elliotson’s successes, began
to employ mesmerism in India, and, in 1846, was placed in charge of a
hospital in Calcutta in order to continue his mesmeric operations.
Most of his cases were elephantiasis of the scrotum, the removal of
which entailed a mortality of 50 per cent., but in 161 consecutive cases
operated on by Esdaile the mortality was only 5 per cent.

The discovery of hypnotism, as distinguished from mesmerism, is due
to James Braid, a Scotch surgeon who settled in Manchester. In
184T, after witnessing a mesmeric seance, he determined to try and dis¬
cover the cause of the phenomena which had been produced. After
a number of experiments, he became convinced that the phenomena
were purely subjective, and not due to any mysterious force or fluid;
and from that time till his death, in i860, he employed suggestion with
success in his practice.

After the death of Braid, the practice of hypnotism practically came to
an end in England, but in France Dr. Li^bault discovered, in i860, that
by suggestion he could induce a condition which he called sommeil
provoqui. He soon gave up ordinary practice, and in 1864 settled at
Nancy and gave himself up to hypnotic work. For twenty years he
devoted himself to the poor, and refused to accept a fee lest he should
be considered guilty of unprofessional conduct. It was not until 1882
that he met with anything but contempt and ridicule ; in that year he
cured a patient who had been treated by Prof. Bernheim for sciatica for
six months without relief. The Professor visited Lidbault, and though
at first sceptical, soon became an eager pupil, and in 1884 published his
great work on suggestion. From that date Liebault became well known,
and doctors flocked to Nancy to study the new method of treatment.

While Li6bault was being ignored or laughed at in Nancy, Charcot
established a school of mesmerism at the Hospital of La Salpetriere in
Paris. For some time there was keen rivalry between the two schools,
but Charcot’s views are now generally discredited, while those of Liebault
have spread over the whole of Europe. In England, the hypnotic
revival, though the way was prepared for it by Braid, arose chiefly
through Lidbault’s influence, one of its leading exponents being Dr
Bramwell, of London.

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137

1915.]

To pass from the history to the nature of hypnotism. Hypnosis
may be defined as a psychical condition in which suggestions are not
only much more easily accepted, but are also realised with an intensity
much greater than is possible in the normal state. The term hypnosis
or hypnotism is rather deceptive, as sleep is only one of the many
phenomena which can be produced, and is certainly not one of the
commonest. The idea of sleep also suggests relaxation and uncon¬
sciousness, but in hypnosis not only is the mind in a peculiarly sensitive
state of consciousness, but the body is capable of extraordinary muscular
efforts.

In the lighter stages the memory is unaffected, though in the stage
of somnambulism there is post-hypnotic amnesia— i.e. in normal life the
patient remembers nothing of what took place under hypnosis. On
being re-hypnotised, however, he will remember not only all that
happened in previous hypnoses, but also the events of every-day life,
many of which he perhaps thought he had forgotten.

Even in the lighter stages the special senses can be altered by
suggestion, either with increase or decrease of their activity. A psychical
dumbness, blindness, or deafness can be produced, and in deeper
hypnosis analgesia and anaesthesia.

As to susceptibility, Schrenck Notzing states that out of 8,705 persons
tried by fifteen different observers, 6 per cent, were uninfluenced, 15 per
cent, became somnambulistic, 79 per cent, were less deeply hypnotised.
Ltebault’s failures amounted to only 3 per cent., while, according to Forel,
every mentally healthy person is naturally hypnotisable. Race and sex
cause hardly any difference in susceptibility, but children over three are
more easily influenced than adults.

It is often said that a person who is easily hypnotised must have
a very weak mind, but all authorities are agreed that the hysterical
and ill-balanced are the most difficult to influence, and that most
lunatics and all imbeciles are quite incapable of being hypnotised at all.

The methods of inducing the hypnotic state are then described, also
the conditions which tend to favour it.

No matter what method is used, the results depend chiefly on the
suggestibility of the subject, and only in a minor degree on the operator,
though obviously some men can enforce obedience to their suggestions
better than others. If, however, the subject offers a real resistance, or
if he has produced a condition of auto-hypnosis, it is almost, if not
absolutely, impossible to induce even the lighter states of hypnosis.

The various conditions in which hypnotism has been used with suc¬
cess are so numerous that it is impossible to do more than mention a
few, such as the different forms of hysteria, including perversions of
sentiment, obsessions and irresistible impulses; functional neurosis of
children; neurasthenia ; dipsomania and drug habits; insomnia and
epilepsy; menstrual disorders and constipation; seasickness and
stammering.

Organic diseases, ot course, cannot be cured, but many of their
symptoms can be relieved.

For therapeutic purposes, as a general rule, only a light degree of
hypnosis is necessary, and latterly Bramwell employs suggestion alone,
without hypnotising his patients.

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EPITOME.

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In surgery hypnotism has frequently been employed to procure
anaesthesia, both before and since the invention of ether and chloro¬
form.

Like all other anaesthetics it has its advantages and disadvantages.
Once anaesthesia has been obtained it can be continued for any length
of time, and can be re-induced by either the written or verbal command
of the hypnotiser when required. Nervousness can be removed. No
preparation is necessary; the process is absolutely safe and pleasant,
and, of great importance in operations on the mouth and throat, there
are no gags, tubes, or other apparatus to get in the way of the operator;
there is no post-operative vomiting; pain after operation, and at sub¬
sequent dressings can be entirely prevented, and frequently the rapidity
of healing is marked.

Numbers of cases of painless parturition during hypnosis have been
reported, and certainly the uterine contractions can be modified by the
action of the voluntary muscles. Pregnant women are more easily
hypnotised than those suffering from nervous diseases, but, though over
90 per cent . of people can be hypnotised, it generally requires several
preliminary attempts before a sufficient depth of hypnosis can be
obtained, and so, until the methods of induction are greatly improved,
the use of hypnotism as an anaesthetic must always be restricted.

Naturally, many attempts have been made to explain how the
phenomena of hypnotism are produced.

Mesmer believed in a vital fluid or force which was transmitted from
the operator to sensitive subjects, and which also existed in metals,
crystals, and magnets.

According to Braid, even thing was due to changes in the patient’s
own brain, one idea becoming dominant through the temporary inhi¬
bition of the other ideas which normally control it. Later, he came to
the conclusion that the only explanation of the condition was the intel¬
ligent action of a secondary consciousness.

Charcot’s views were simply those of the mesmerists, only that he
terms the subjects hysterical instead of sensitive.

The Nancy school reproduces Braid’s earlier and discarded theory
of psjchological inhibition, and attributes all the phenomena to
suggestion.

The theory which, according to Bramwell, affords the best working
hypothesis is that of the subliminal consciousness. It presupposes a
secondary consciousness, capable of exert'ng powers over which we
normally have little or no control; and certainly the phenomena of
hypnotism all show increased, not diminished, mental power.

J. R. Lord.

2. Clinical Psychiatry.

A Comparison of the IVassermann Reaction among the Acute and the
Chronic Insane. {Journ. Nerv. and Ment. Vis., Sept., 1914.)
Darling, J. A., and Newcomb, P. B.

By a routine application of the Wassermann test to the blood serum
of all new admissions to the Warren State Hospital, very frequently the

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attention was first directed to the luetic origin of various mental disturb¬
ances which presented at first glance the clinical features of other
psychoses. This was especially true in numerous instances of paresis
and cerebro-spinal syphilis simulating a manic attack, the disturbed
delirium of dementia prrecox, or the agitated confusion of an artero-
sclerotic or senile psychosis. This innovation was extended to all the
patients already resident. The technique adopted is then described.
Eight hundred and forty-nine specimens of blood were obtained from
those patients who had been admitted prior to such tests becoming a
routine practice, with the result that 5‘o6 percent, were positive. An
examination of 452 admissions gave a positive result in 20^4 per cent.
The obvious explanation is due to the brief and fatal termination of the
cases of paresis and cerebro-spinal lues, which comprised 12'16 of the
recent cases. In the remaining 8‘i8 per cent, syphilis was not held
accountable for the psychosis. Of the cases already resident (849) only
two were attributable to syphilis, leaving 4^94 per cent, with positive
reactions in whom syphilis did not cause the psychosis. Thus, the
prevalence of this disease in the chronic insane differs but little from
its probable prevalence in the community at large. J. R. Lord.

Case of Gamer’s Symptom-Complex in a Military Prisoner [Syndrome
de Ganser chez un detenu militaire: contribution a Petude des
rapports de la simulation et de la dimence prlcoce\ {Rev. de
Psyehiat., May , 1914.) Livet.

The case reported by Dr. Livet is chiefly of interest as bearing on
the question of the simulation of insanity. The patient, a man, set. 25,
a soldier in the Foreign Legion, with a bad criminal history, was court-
martialled for striking his superior officer, and, having acted in a very
eccentric manner, was sent to the asylum for observation. The atypical
character of his symptoms, and their sudden development under the
threat of punishment, led to the diagnosis of malingering, but at the
same time their very puerility and exaggeration appeared to indicate an
underlying condition of debility. And the subsequent development of
mannerisms, stereotypisms, slight catatonic manifestations, and emotional
indifference, confirmed the opinion that the case was one of dementia
pnecox. Both in the early phase, in which the author considers that
there was undoubtedly conscious simulation, and in the later stages of
enfeeblement, the patient showed in a marked degree the symptom of
irrelevance of reply (Vorbeireden), described by Ganser in cases of
hysterical dreamy state. Dr. Livet remarks that the occurrence of this
symptom-complex of Ganser is not infrequent at the beginning of
dementia praecox in prisoners and soldiers, and that in such cases it is
to be regarded as a pathological simulation. It tends to persist as a
stereotypism marking the special conditions of the milieu in which the
psychosis developed. The point is of practical importance, as the
presence of this symptom, with its obvious suggestion of malingering,
may lead the hasty observer to overlook the existence of the real disease
beneath it XV. C. Sullivan.

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140 epitome. [Jan.,

A Contribution to the Study of Insanity in Twins. \Con 1 ributo alio
studio della follia nei gemelli\ {Arch, di Anthrop. Crim., May~
June , 1914.) Vidoni and Tanfani.

After a critical review of the literature of the subject, the authors
give a short report of a case of male twins, a;t. 33, both mentally defec¬
tive, and one presenting in addition an imperfectly systematised
delusional state, with symptoms of impulsivity, negativism, and verbigera¬
tion. The twin with the more active development of mental disorder
had been exposed to two stresses which had not operated in the case of
his brother; he had been called up for military service, and he had
married. It was after some months of soldiering that the first symptoms
of his dementia praecox appeared. The family history showed an
exceptional degree of hereditary taint: the parents were first cousins,
and insanity, mental debility, and alcoholism abounded in the stock;
the first-born child in the family became insane, the second was
eccentric and feeble-minded, and then seven abortions intervened before
the birth of the twins.

Discussing the case in connection with the theoretical views which
have been advanced as to the nosological position of folic gemellaire ,
the authors conclude that their case goes to show that the insanity of
twins is to be regarded, not as a definite clinical group, but merely as a
manifestation of mental degeneracy—it is a particular case of the
insanity of invalid brain. They further remark that the development of
dementia praecox in one of the twins in their observation points to the
significance of innate defect as a condition precedent to the evolution
of this disease. A somewhat inadequate bibliography is appended to
the paper. W. C. Sullivan.

Acute Alcoholic Delirium [Du delire alcoolique aigu\ {Pull, de la Soc.
de Mid. Merit, de Belgique , February , 1914.) De Block.

This paper gives a cursory review of the clinical aspects of. alcoholic
delirium as observed in a series of 167 cases treated in the psychiatric
clinic of the University of Liege. The ordinary form of alcoholic
liquor consumed by the working classes of Liege is gin, while beer and
wine are of quite secondary importance, and absinthe is only used to a
negligible extent. The author suggests that local variations in the
clinical features of delirium tremens may be in some measure attribu¬
table to difference in the sort of liquor drunk in the several regions, but
it does not seem possible to detect in his cases any special characteristics
that can be regarded as distinctive of gin alcoholism. On the whole,
the hallucinations and delusions noted are singularly like those met
with in cases of the disease occurring in urban populations under similar
conditions as regards education and industry, whether the prevalent
drink be wine, beer, whisky, or other form of spirits. The mortality in
the series was fairly low—47 per cent., but it is difficult to compare this
figure with the results of other observers, as no details are given
regarding the age-distribution of the cases, their sexual incidence, and
so forth. Of the seven patients who died, three had epileptiform con¬
vulsions, a fact which goes to confirm the view that this symptom is of
bad prognostic import. Dr. De Block had observed a few cases of the
type described by German writers (Bonhoeffer, Schroeder, Pilcz) as

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acute alcoholic hallucinosis, in which there is a sudden development of
auditory hallucinations with more or less systematised persecutory ideas.
While admitting the reality of this condition as a clinical entity, Dr. De
Block points out that the occurrence of cases intermediate in character
show it to be essentially connected with ordinary delirium tremens.
He does not refer to the possible influence of neurotic heredity in deter¬
mining this special evolution of alcoholism.

W. C. Sullivan.

Epilepsy and Traumatism \Epilepsie et traumatisme]. (Bull. Soc. Clin.
Med. Ment., April, 1914.) Marie , A.

Marie shows a naval gunner, set. 26, who met with an accident in
1906, causing a large wound over the left side of his scalp, followed
almost immediately by epileptic fits. He recovered from these under
bromide, but they left some mental impairment. He was no longer fit
for the naval service, but was employed as a nurse in the hospital.
While acting as nurse in 1907 he met with another accident, falling on
his head; the fits again appeared with mental dulness. He recovered
for some months, then had another seizure in Paris, where he was sent to
an asylum. There he was dull, confused, and morbidly emotional, had
marked motor signs, oculo-pupillary troubles, speech affected, slow and
scanning as if he had something in his mouth; no dysarthria nor
dysphasia ; he could read, write, recognise and name objects seen and
felt. No history or signs of syphilis or alcohol. The mental symptoms
have almost disappeared, and the motor signs are much less evident.
The writer suggests surgical interference as the scar on the scalp is so
well defined, extending over the motor area of Broca. The chief
interest in this case lies in the fact that a head injury was on two
occasions followed by epilepsy with transient mental and motor
symptoms. E. Montgomery.

The Paralytic Syndrome in a Diabetic; death from Acetonemic Coma
(Syndrome paralytique ches une diabitique; mort par coma aclto-
ncmique terminal]. (Bull. Soc. Clin. Med. Ment., June , 1914.)
Marchatid , Z., and Petit , G.

. Diabetes is rare as a cause of the paralytic syndrome. The few cases
recorded lack pathological confirmation. The authors of this paper had
under their care recently a woman in whom the paralytic syndrome
developed some days prior to her death from diabetic coma, and in
whom the post-mortem clearly showed that the condition was the result
of auto-intoxication, and not of a diffuse meningo-encephalitis. The
patient, a woman, ret. 60, had been for some years subject to attacks of
depression, with threats of suicide, phobias, etc. The mental symptoms
leading to certification only began a month before her admission to the
asylum. She became confused, disorientated, and paraphasic, and was
stated to have visual hallucinations. Her previous health had been
good; there was no evidence of syphilis, and her diabetes was only
diagnosed on admission to the asylum. Her friends had noted, how-
ever, that for some time she had been getting weaker, and suffered from'
increasing sleepiness. On admission she was quite disorientated in time
and space, recent and distant memory much impaired, had difficulty in

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EPITOME.

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naming objects, and could not make simple calculations. She was
distinctly depressed, with hypochondriacal and melancholic ideas, and
had no grandiose delusions. There was marked disturbance of articula¬
tion, especially with test words; her pupils were unequal, her reflexes
exaggerated, and her tongue and extremities were tremulous. The
breath had a strong odour of acetone, and her urine contained sugar.
In a few days she passed into a state of diabetic coma, in which she
died.

The post-mortem showed an intense congestion of the meninges,
which were milky, and diffusely adherent to the cortex. No granulations
in the fourth ventricle, and no dilatation of the lateral ventricles. No
atheroma of the basal vessels. Portions of the motor cortex were
examined, and showed the following changes: The pia is thickened,
oedematous, adherent to the cortex in parts, and infiltrated with blood.
There is no definite meningeal haemorrhage, but the under surface of
the pia exhibits many extravasated red blood-cells. There is no trace
of vascular or other inflammation, and the vessels are much dilated.
The cellular lesions are very marked, and differ entirely from those
ordinarily found in intoxications. Not only are the chromophil elements
intact, but they show an unusual affinity for the stain. The cell bodies
are slightly atrophied, and contain areas of pigmentation; the nuclei
are deformed, oval, and excentric; there is no increase in the number
of satellite cells; no lesions in the vessels or the neuroglia. The tangential
fibres are reduced in number in the frontal lobes. Similar cell changes
are present in the cerebellum and bulb.

We have here, then, a paralytic syndrome undoubtedly toxic in origin,
and comparable with that resulting from alcoholism. The diffuse menin¬
geal haemorrhages may be looked on as a true purpura of the pia mater.

W. Starkey.

3. Treatment ot Insanity.

The Treatment of General Paralysis by Trephining and Intra-rneningeal
Injections of Spirillicides. [Ponctions clrebrales et Instillations
spirillicides intramlningees dans la P.G.]. {Bull. Soc. Clin. Med.
Ment., Feb.. 1914.) Marie and Levaditi.

Levaditi and Mutermilch have shown in 1911 that the serum of
animals injected intra-peritoneally with salvarsan had strong micro¬
bicidal powers in vitro, and that these powers persisted after the serum
had been subjected to a temperature of 55 0 C.

The authors of the paper under review give the results of an attempt
to treat general paralysis by injecting the serum of salvarsanised rabbits
intra-meningeally. The animal is injected with salvarsan intra venously,
the dose employed being in the proportion of o'o7 grm. to the kilo¬
gram of body weight. Violent shock results, but recovery soon occurs.
One hour later it is bled to death, and the serum is decanted and
subjected to a temperature of 55 0 C. for forty-five minutes; it is then
ready for use.

Two cases of general paralysis were treated in the following manner :

The skull was opened under chloroform anaesthesia by a de Martel

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1915.]

trephine, the site being the anterior temporal region on each side.
The dose employed was 5 c.c. on each side, and it was introduced by
means of a bent needle, directed at first forwards, then towards the
parietal region under the dura. The serum was injected slowly and
steadily, and the openings in the skull closed. In both cases there
was a severe reaction within a few hours—high fever, vomiting, prostra¬
tion, partial convulsions, and later a catatonic condition. These
symptoms persisted for three or four days, and then passed off, leaving
the patients distinctly improved both mentally and physically. The
improvement was most marked in the earlier case. Since then the authors
have treated ten more cases in the same manner, without any bad
result, and with marked benefit in all. It is too early to say if the
improvement is permanent, but the treatment seems to hold out some
hope at least, and is worth an extended trial. It is important in
operating to avoid puncturing the brain substance, lest the injected
fluid should destroy any of the motor areas, and the trephine opening
should not be made in the temporal fossa, lest the larger epicranial
vessels, or branches of the middle meningeal, be injured.

W. Starkey.

The Use of Neo-salvarsan in Mental Deficiency. ( Glas. Med. fourn.,
Oct., 1914.) Findlay , L.

Before the introduction of the Wassermann test, some authors, e.g .,
Ziehen, had found evidence of syphilis in as many as 17 per cent, of the
cases, but Shuttleworth, on the other hand, concluded that only 1 per
cent, of cases of idiocy were due to this malady. With the help of this
test Fraser and Watson found evidence of lues in 60 per cent, of 205
mentally defective and epileptic children, and Robertson and the author,
working with the same technique, obtained a positive Wassermann
reaction in 59 per cent, of fifteen mentally defective children. Dean
concluded that at least 15 per cent, of cases of idiocy were due to
syphilis, and Krober puts the figure at 21 per cent.

The highest percentages which have been obtained by workers in the
West of Scotland using the Browning, Cruikshank, and M’Kenzie
method, have caused some authorities to question the diagnostic value
of the test. In the absence of both a history of lues and specific
stigmata, his opinion was confirmed that the Spirochceta pallida is a
frequent cause of idiocy, and also that salvarsan is exceedingly effica¬
cious in the treatment of syphilitic manifestations, by the following
experience in the treatment of mental deficiency.

Case i. —E. H—, female, set. 8, one of a family of five, all of whom
are living. First seen November 14th, 1912. Father and mother alive
and well. The other children are normal, and there is no specific
history in the family.

Patient began to walk at fifteen months, and to talk at.eighteen
months, but she has never talked well. Teething commenced at eighteen
months; the upper incisors have never appeared. She was always a
backward child, has never been to school, and is subject to nervous
attacks, during which shaking of the hands and feet occurs. She would
never associate with other children, could not be sent messages, was not
able to dress herself, and frequently soiled her clothes. Shortly before

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[Jan.,

coming under observation she had been looked upon as a cretin, and
was treated with thyroid gland without any benefit.

She is pale, nervous, mentally deficient to an extreme degree, and
undersized. There are no specific stigmata.

Patient, her mother, and four brothers and sisters all give a positive
Wassermann reaction.

She was treated with potass, iodid. and hydrarg. perchlor. for
four months, but with no improvement. Between April 8th, 1913, and
May 12th, 19x3, she received in addition four intra-muscular injections
of neo-salvarsan in doses varying between 0-4 and o - 6 grm., in all i - 8
grm. By the conclusion of the series of injections she had distinctly
improved, and was brighter mentally, but the pain and induration con¬
sequent on the treatment had been so severe that; it was decided to
administer the drug intravenously. From May 19th to June and, ___

she received three intravenous injections in doses varying between 0*3
and o'4 grm. at weekly intervals, i.e., in all 1 05 grm. The child by this
time had still further improved; she was brighter, was beginning to
play with other children, and could be trusted to go messages. From
September 9th till September 23rd, 1913, she received other four intra¬
venous injections, the doses varying between o’35 ando'25 grm. These
last four injections were administered under an anaesthetic, as the child
had hitherto been very much afraid at the time of the operation. In all,
she received 4 grm. of neo-salvarsan.

At the termination of the salvarsan therapy she was greatly im¬
proved.

The child was last seen on June 9th, 1914, when the Wassermann and
luetin reactions were definitely negative. She had not received any
mercury since November, 1913. The improvement in both her mental
and physical states has continued.

Case 2.—W. G—, male, set. 8$. First seen on May 9th, 1913, on
account of not making progress at school, which he had attended for
three years. He is one of a family of three, the rest of which are healthy
and intelligent. There is no specific history in the family (father is a
soldier), nor of mental disease, nor of consanguinity.

Patient never goes out to play with other boys, nor can he defend
himself against them. He cannot go messages, nor make the slightest
attempt at reading, and is only able to recognise pictures of very few
common objects.

He is moderately well-developed physically, has a somewhat small
head, and a dull apathetic expression. There are no specific stigmata.
Wassermann reaction is definitely positive. From May 16th till June
23rd, 1913, i.e., during a period of five and a half weeks, he received
five intramuscular injections of neo-salvarsan in doses varying between
o'3 and o’45 grm., in all i’9 grm. At the same time he was given
potass, iodid. and hydrarg, perchlor. per os.

After four injections his mother stated that he was distinctly brighter,
and for the first time cried on entering the dispensary, apparently
recognising that he was going to receive an injection, which always
caused considerable pain. He could now go messages, and was able
to read such small words as “cat” and “dog,” which he could not do
previously. Four months after the last injection he had been put into

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Treatment of 1 insanity.

*9*5-]

a higher class at school, and was playing with other boys, but still
allowed them to “knock him about/’ Six months after the last
injection the Wassermann action was still positive, but weak. Potass,
iodid. and hydrarg. perchlor. were being still continued.

Seen on April 25th, 1914, ten months after last injection. Had not
received potass, iodid. or hydrarg. perchlor. for six weeks. He had
lost the dull apathetic look, and for the first time conversed freely with
me. He is in the same class as his brother, who is 2^ years younger,
but is learning just as quickly. He can go messages, plays with other
children, and is now able to defend himself against boys of his own age.

Case 3.—G. G—, male, aet. 7^. First seen on February 24th, 1913,
because he had been dismissed Irom school on account of his inability
to learn.

Father and mother alive and well. He is one of a family of three, all
of whom are living. There is no history of miscarriages or still births, or
of syphilis in parents or family. The other children are quite normal.

Patient was a healthy baby at birth, walked at twelve months, and
talked at eighteen months. Until he was sent to school he seemed
quite a normal child. At school he is well behaved, but is making no
progress, and his mother states that he is gradually getting duller. He
used to go out to play, and could be sent messages, but now he takes no
interest in anything. If thwarted at home he is subject to severe fits of
passion, which will last for one or two hours, during which he is
destructive. He has also not been thriving of late.

The Wassermann reaction is strongly positive in both the patient and
his mother.

On March 25th, 1913, he received an intramuscular injection of
c '35 g rm> neo-salvarsan, which caused great induration and tenderness,
and in consequence it was decided to administer the drug intra¬
venously. From April 8th till May 6th, i.e., a period of four weeks, he
received five intravenous injections of neo salvarsan in doses varying
between o'3 and 0^45 grm., in all 175 grm. At the same time he was
treated with mercurial inunctions.

As a result of the treatment he improved considerably. On
September 7th he had been back at school, and seemed more interested.
He could again be trusted to go messages, and always brought back the
correct change, which before he invariably spent on sweets. Violent
fits of temper had ceased, and his general health had also improved,
but he was still very backward mentally. After this he was lost sight
of, but recently it was learned that about Christmas, 1913, i.e., seven
and a half months after the last injection of neo-salvarsan, he commenced
to take convulsions, and suffered from severe headaches. This state
of matters persisted until the middle of March, 1914, when he developed
blindness. Sion afterwards the convulsions and headaches became
more violent and head retractions appeared. He died three weeks later.

Case 4.—W. B—, male, set. 8i. First seen on January 22nd, 1913.

Father and mother are alive and welj. Mother has had six pregnancies.
Patient is the first, and the second was still-born. There have been no
miscarriages. The other children are alive and well. Patient learned
to walk at two years, and to talk at three years, but he has never been
bright, and never been to school.

LXI. 10

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When first seen he was an undersized mentally deficient child, most
of his time sitting in a chair with his head rolling from side to side. He
could walk, but very unsteadily, and nearly fell. His head was large
and square, with prominent forehead, and of a definite hot-cross bun
shape. Round the mouth were linear cicatrices, and an eczematous con¬
dition implicating the mucous membrane of the lips. Both upper
central incisors were notched, and interstitial keratitis was also present.

Between October 16th and November 8th, i.e ., a period of three and
a half weeks, he received four intravenous injections of neo-salvarsan in
doses varying between o - 3 and o‘4 grm.; in all i '3 grm. neo-salvarsan
was administered. At the same time mercury was prescribed. After
the injections he seemed more interested in things, and commenced to
run about and play, but on account of his eyesight getting worse he
could not be sent to school.

One month after the last injection the Wassermann reaction was still
strongly positive. His general health was much improved, he was brighter
mentally, and could go messages. His eyesight was not so good, and
seemed to be getting rapidly worse.

Seen again on June 18th, 1914: General health continued good, he
was mentally brighter, but was now completely blind. In the right eye
there was a slight degree of optic atrophy with disseminated choroiditis,
and in the left an extensive cataract.

Each of these cases was a very marked example of mental deficiency,
three of them being frankly idiots. The treatment had a most salutary
effect, and although it did not bring them up to a normal level, it made
it possible for two of them to be educated and to look after themselves.
In milder cases, and especially if the treatment were commenced earlier,
it might be possible to obtain complete cures.

Conclusions. —(1) Syphilis is a frequent cause of idiocy.

(2) In syphilitic idiocy there may be no luetic stigmata.

(3) Neo-salvarsan when introduced intravenously or intramuscularly
has a very marked effect in improving the mental condition.

J. R. Lord.

4. Pathology of Insanity.

The Treponema of General Paralysis \Lc treponcme de la paralysie
gene rale']. (Bull. Sac. Clin. Med. Ment., June, 1914.) Marie, A.,
and Levadili, C.

The authors attempt to show that the treponema of general paralysis
differs biologically from that of ordinary syphilis. The hypothesis that
a special syphilitic virus is concerned in the aetiology of tabes and
general paralysis has been discussed by many clinical observers. They
have remarked the occurrence of general paralysis or tabes in several
subjects infected from the same source, the frequency of conjugal
general paralysis, and the cases recorded by Morel, Fournier, Babinski,
Mott, Brossius, Beaussart, and Marie have demonstrated that certain
sources of the specific virus undoubtedly determine the occurrence of
cerebro-spinal infections. The discovery of the treponema in the'

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brains of general paralytics, and its inoculability in the rabbit, permit
us to attempt to verify this hypothesis.

The authors’ virus was obtained from a general paralytic who had
been syphilised fifteen years previously. Blood from this case was
injected into the skin of the scrotum in several rabbits, and in one
animal produced cutaneous lesions with many spirochaetes. This
virus was then passed through a series of rabbits, and the results com¬
pared with those due to the virus of ordinary syphilis (Truffi’s virus),
with which experiments had been conducted during the past six
years.

The following differences were noted :

(1) Period of incubation. —In the case of the general paralytic virus

this is particularly long; 127 days in the first inoculation, 94, 46,
and 49 days in succeeding ones. In Noguchi’s two positive cases it
was 87 and 102 days (cerebral virus); in those of Graves, working
with a blood virus, it was 49 and 63 days. % .

(2) Character of lesions. — (a) Macroscopically. The general paralysis
virus produced superficial lesions, erosions covered with scales, and
surrounded by a zone of dermic infiltration, and never the deep,
indurated ulcers such as result from Truffi’s virus.

(b) Microscopically. The lesion resulting from the general paralysis
virus consists of a thickening of the dermis, and an infiltration of the
papillae and all the superficial layers of the dermis with mononuclear
and plasma cells. The epidermis desquamates, and finally ulcerates.
There are few signs of endarteritis, but an intense perivascular inflam¬
mation without obstruction of the vessels. On the contrary, in the
lesions due to Truffi’s virus the infiltration and endarteritis are marked,
and the deeper tissues much more affected. Finally, and most note¬
worthy, is the high elective affinity which the general paralysis virus shows
for the surface epithelium. The treponemas multiply by preference at
this level, separating the cells from the basal layer, and even penetrating
into the cells.

(3) Evolution. —The lesions resulting from the general paralysis virus
tend to heal with extreme slowness (169 to 195 days).

(4) Virule/tce. —Truffi’s virus, even after numerous transmissions
through rabbits, is still capable of infecting the lower apes (24 days’
incubation), and the chimpanzee (45 days). The general paralysis virus
is incapable of conveying the infection to apes or chimpanzee, and is
apparently pathogenic only for the rabbit.

(5) Crossed immunity. —The spontaneous cure of a chancre in the
rabbit produces immunity. But, from an experiment of the authors, it
appears that the general paralysis virus does not give immunity as
regards Truffi’s virus, and inversely. A rabbit cured of the general
paralysis lesion, and four controls, were inoculated with Truffi’s virus.
All contracted syphilis. Another, cured of the ordinary lesion, and
two controls, were similarly inoculated with the general paralysis virus.
All showed spirochaetes on the forty-ninth day. This research is still
being carried on.

If, in addition, one takes into account the feeble pathogenicity of the
spirochaetes from the brain of the general paralytic for the rabbit (the
authors’ experiments ^ud the sixty negative inoculations of Forster ami

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Tomasczewski), it is difficult to doubt that a marked biological difference
exists between the virus of the general paralytic and that of ordinary
cutaneous and mucous syphilis. The authors consider that the trepo
nema of general paralysis is a separate neurotropic variety of the
Treponema pallidum. Its affinity for nervous tissue explains the late
development of cerebral manifestations; its presence, possibly in
symbiosis, with the ordinary treponema in certain sources of infection,
would account for the occurrence of general paralysis in subjects
infected at these sources, and not in otheis.

The uselessness of arsenical treatment in general paralysis must not
be attributed to any special resistance of this virus to arsenic, since
experiments in rabbits have shown that the lesions due to the general
paralysis virus are amenable to treatment with arseno-benzol.

W. Starkey.

The Relations of Internal Secretions to Mental Conditions. (.Monthly

Cyclop ., Jan., 1914, and Atner. Jourti. Med. Sci., Aug. 13///.)

Trankl-Hochwart , L. v.

In the so-called “formes frustes ” of Basedow’s disease the exoph*
thalmos is often altogether absent or only suggested. They are often
grumbling, hypochondriac, melancholic, and egotistic persons. In com¬
pletely developed Basedow’s disease manic features are often pro¬
nounced. They are talkative, spasmodic in their thoughts and actions,
and sonictimes incline to witticisms. Erotic subjects are preferred, and
they are given to sexual excesses. Opposed to the picture of Basedow’s
disease, of hypertrophy of the thyroid-gland tissue, is the picture of
atrophy and degeneration. Most striking is the condition of the adult
myxcedematous patients. The principal factor is the complete lack of
emotion. A considerable role is ascribed to the thyroid gland in
emotional life. According to Levi and Rothschild, it is the “glande de
l’emotion.” The similarity of the picture of fear emotion and that of
Basedow’s disease should be remembered : The protuberance of the
bulbi, tremors, tachycardia, congestions which alternate with pallor,
outbreaks of perspiration, diarrhoeas, etc. The myxcedematous, accord¬
ing to Charcot, may be compared to hibernating animals : dull-witted,
indifferent, unable to work, disinclined to sexual activity ; the memory
gradually decreases, the power of judgment becomes minimal, and the
patients often lie in bed apathetically for days, almost without desire for
food or drink. Severe psychoses are by no means rare in these patients.

As regards the parathyroids , the author has described psychoses in
individuals who had fallen ill of typical tetany. These individuals
normally are excitable, timid, uneasy, quarrelsome, and inclined to out¬
breaks of temper. Depression is occasionally present, but is not one of
the dominant symptoms. In the psychoses conditions of temper and
excitement predominate. The author found among his old patients
with tetany several who had grown excitable and irritable. In those
who had myxcedematous phenomena, symptoms of mental lassitude
appeared which were not recognisable in the other forms. In strumec-
tomised animals peculiar psychic changes have been described. Blum
mentions hallucinations in strumectomised dogs, as well as changes
of characteristics, idiocy, and pathologic motor phenomena. Horsley

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and Pineles saw similar phenomena in monkeys. Erdheim observed
conditions of excitement in rats, and stated that these are connected in
some way with tetany, as on the days when the animals are excited
tetany often reappears.

Basch and Klosevoigt, referring to the feeble intelligence of animals
whose thymus had been extirpated, speak of an “ idiodie thymoprivia.”

Hypophyseal affections must be divided into two large groups, acrome¬
galia, and the dystrophia adiposogenitalis. Boyle and Beadles, among
3,000 necropsies of the insane, found tumours in twenty, six of them
hypophyseal. The number of actual hypophyseal pyschoses is some¬
what over-estimated, but the fact that psychoses are so frequent in
affections of the pituitary body gives food for thought, in spite of their
association at times with the destruction of tissue in other parts of the
brain. The author has seen many cases of pituitary body tumour,
and has noticed a psychic change, a peculiar indifference, a certain con¬
tentment, a euphoria which is not in harmony with the symptoms, such
as headache and blindness. The patients are calm, and have a childish
confidence in the doctor. The sleepiness of the patients is pronounced,
but if they are forced to arouse themselves, their intelligence has not
suffered nearly so much as we would be led to believe by the outward
impression they made.

The psychic factor may best be studied by observing operated cases.
The author has seen cases operated on by the Schloffer (cases of v.
Eiselsberg and Hochenegg), or the nasal method of Hirsch. It is
remarkable how lively, agile, and communicative the patients become.
The entire psychic condition of the corpulent person partakes of that
of individuals with constitutional obesity. The peculiar mental slow¬
ness, indecision, good nature, and sleepiness of these people is proverbial.
Loss of hair is not uncommon.

It is not uninteresting to compare the acromegalic with the physiologic
giants. They have often a peculiar heavy manner and lack of initiative.
The psychic peculiarity of hypophysis patients is of interest from the
fact that the animal experiments of Cushing, in Baltimore, and Aschner,
in Vienna, showed that in hypophysectomised dogs the psychic changes
correspond with those of human beings. According to Cushing,
animals with hypopituitarism become psychically abnormal: at times
they are lazy and sleepy, then playful and excited.

If in early childhood tumours (teratoma) develop in the pineal gland
a picture is presented which is more intelligible since the observations
of Gutzeit, Ogle, Oesterreich, Slavik, Neumann, Marburg, Bailey, and
Jelliffe. The features of premature sexual development are combined
with an unusual development- of fat. In a boy, aet. 4^, who had
always been large and somewhat fat, the genitals developed remarkably.
He had the symptoms of a cerebral tumour (headache, vomiting,
epileptic attacks, paralysis of the eye muscles, and choked disc). The
necropsy findings show a teratoma of the pineal gland. One point in
this observation is of importance, the early development of the mental
condition. The boy was over-intelligent, and had an inclination to
discuss ethical philosophic questions. In his fifth year he showed the
same psychic peculiarities that are displayed by youths during puberty.

There are also signs of early psychic development in the cases of

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Oksterreicli and Slavie and Raymond and Claude. The hypothesis
therefore was that the pineal gland was to be considered among the
blood glands, and that it influenced genital development. Its absence
causes premature genital development, and psychic development corre¬
sponding to the age of puberty.

Of the abdominal glands the pancreas and its internal secretion play
a large part in relation to diabetes. Diabetics often show mood
anomalies, and we speak of actual diabetic psychoses.

The study of suprarenal capsule affections gives us more positive points
of knowledge. The connection between disturbances of brain develop¬
ment and hypoplasias of the suprarenal capsules is of importance
in the subject under discussion. Leri, in three cases of melancholia,
found destruction of the suprarenal capsules. There are occasional
cases of Addison’s disease with a tuberculous destruction of the organs
mentioned. These individuals are weak, exhausted, and hopeless, in
contrast to the euphoric patients, with tuberculosis of the lungs.
Irritability and depression are almost always present. Psychoses of
various kinds have also been observed, depression seemingly pre¬
dominating. J. R. Ixjrd.

A Note on the Relative Weight of the Liver and Brain in Psychoses.

( Journ. Nerv. and Merit. Dis., July, 1914.) Myerson , A.

This is the first of a series of papers concerning the condition of the
organs in the psychoses. A relation of brain changes to many of the
psychoses has net as yet been determined, and there is at least some
ground for expecting that light on the pathology of the psychoses may
come from a systematic study of the organs.

The liver has been the first organ selected to be studied, and this
paper concerns itself entirely with the weight of this organ, as compared
with the weight of the brain, in persons dying in Taunton State Hospital.
The one organ of the body which under normal conditions is heavier
than the brain is the liver, and therefore the weight ratio affords a con¬
venient measure of orientation.

At twenty-five years of age the average liver weight in males is 1,600-
1,700 grm., according to Vierordt. The average brain weight at that
age in males is 1,290-1,350 grm. In the female at the corresponding
age and period of life, the average of the liver is from 1,520-1,600 grm.,
and the average weight of the brain 1,200-1,275 grm., that is to say the
ratio of the liver to the brain is, roughly speaking, somewhere around
16-13.

The brain at the age of forty, or thereabouts, reaches its maximum
weight, and from forty to sixty there is a slow, steady decline, although
until the very advanced senile stage the decline is not very marked.
The liver weight remains stationary from thirty to forty and then under¬
goes a more rapid decline than does the brain, so that at seventy to
seventy-five its weight is somewhat less than the brain weight, even in
normal old people. However, in the normal senile, the weight of the
liver is rarely under 1,100 grm.

In looking over the factors that enter into the cause of change in
ratio of the brain and liver, the first was the state of nutrition. That
emaciation markedly reduces the weight of the liver has been borne out

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in animal experiments. Under emaciation, then, changes in ratio of
these two organs are to be expected even in young people, since the
brain suffers but little loss of weight in starvation. Therefore the cases
have been placed under two headings—emaciation and non emaciation,
and they were free from any local disease of the liver itself, such as
carcinoma, abscess, cirrhosis of definite type, etc., and nutmeg livers
have been excluded.

Series r.— (a) Emaciated senile dementia : twenty-five cases. Most
were females. Average weight of the liver, 940 grm.; average brain
weight, 1,070 grm.

{/>) Non-emaciated senile dementia: twenty-five cases. A little over
half of whom were males. Weight of liver averaged 1,270 grm.; average
weight of the brain, 1,270 grm. There is in this series a change of the
liver ratio to the brain ratio, regardless of the state of nutrition. The
liver has suffered an atrophy which is very much more marked than any
corresponding change in the brain, and the microscopic examination
showed, in a great many of the cases, a very marked fatty infiltration of
the liver, so that the actual reduction of the liver tissue was much more
extensive than is evident from the weight figures themselves. In other
words, while emaciation is responsible for much of the reduction of the
weight of the liver in senile dementia, there is a reduction of the liver
weight irrespective and independent of emaciation.

Series 2.—A group of Dr. E. E. Southard’s cases of dementia praecox
have been taken, as considered in his paper on “ Focal Lesions in
Dementia Praecox.” He found the liver weights of the males to average
1,369 grm., in the females, 1,257 grm., as compared with the normal
male, 1,579 grm., normal females, 1,525 grm. The brain weight,
though reduced somewhat from the normal, was less reduced. Since a
large number of dementia praecox cases die emaciated, the loss of
weight may be due to emaciation. Myerson analysed some of his figures
a little more closely, and can present the following facts. Eight cases
of dementia praecox in the third decade (from twenty to thirty years of
age), showed a liver weight averaging 1,438 grm., brain weight, 1,341
grm.; in the fourth decade, the liver weight averaged 1,192 grm., the
brain weight, 1,220 grm. In the fifth decade the liver weight averaged
1,350 grm., the brain weight, 1,250 grm. In the sixth decade the liver
dropped still further, and after the sixth decade showed the usual senile
change.

Series 3.— (a) Eleven cases of emaciated general paretics, liver weight,
1,33° grm., brain weight, 1,277 grm. AH these cases were forty years
or under. The liver weight dropped from the normal quite markedly,
but has not reached the weight of the brain. (l>) In fourteen non-
emaciated paretic cases, the liver weight, 1,470 grm., brain weight,
1,250 grm. It will be seen that in cases of paresis, even with emacia¬
tion, the liver does not lose in weight to the extent that it does in many
cases of dementia praecox. Some of the author’s own cases of dementia
praecox, not there recorded, show liver losses down to 800 grm., and reach¬
ing in some cases even to 600 grm., while practically none of the paretic
cases show any such change. This may be due to a connective tissue
increase in the livers of paretics, but there is very little such increase in
paresis, and the rnaintenance of the weight of this organ in this disease

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EPITOME.

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cannot be accounted for. It is probable that the brain weight in paresis
is not a fair index of the brain changes, since there is a large increase in
the neuroglia which makes up for the loss of weight in other directions,
eg., in the nerve-cells.

Series 4 .—A group of young epileptics, from twenty-five to forty,
dying of sudden diseases, and all well nourished. Such factors as
tuberculosis, diarrhcea, emaciation, etc., were eliminated. Most of the
cases died of suffocation, acute lobar pneumonia, oedema of the lungs,
etc. In thirteen cases, the liver weighed 1,150 grm., the brain 1,260
grm., a very marked reversal of the expected ratio. In seven cases, the
liver weight averaged 1,350 grm., the brain 1,300 grm. That is to say,
there was in the smaller series a somewhat heavier liver than brain, and
in a larger series a much lighter liver than brain. So small a series is
not sufficient from which to draw conclusions, nevertheless it points out
a line of research in epilepsy. In looking over the protocols there are
more changes recorded in the organs of epileptics than are recorded in
the organs of paretics. That is to say, on superficial investigation there
seem to have been more definite organic changes in a disease not
known to be organic, than in a disease definitely known to be organic.
Whether these changes are due to the epileptic attacks or cause them
can only be determined by an extensi\e study of a long series of cases.
It would even be necessary to note whether these changes showed a
definite relation to the number and severity of the attacks, or whether
they are very marked in those individuals dying after only a few
attacks, etc.

A point which the author wishes to make is that senile dementia and
paresis have one feature in common, which is that the changes in the
brain found in both these conditions select the frontal lobe as their first
and foremost place of incidence. The explanations for this, which vary
from the vascular distribution, venous drainage, and biological order of
development, are, on the whole, unsatisfactory. Not enough study has
been done on the changes in the organs in general paresis and senile
dementia. For example, Alzheimer, in his elaborate monograph on the
histo-pathology of general paresis, dismisses the changes in the organs
in a brief page or two, although admitting that there may be diagnostic
changes in other places than the brain. It seems possible that there
may be a grouping of bodily changes which brings about changes in
the brain, and that even in a disease where brain pathology is a definite
field of knowledge, investigation should be carried on to discover
whether or not there are corresponding changes in the organs.

J. R. Lord.

5. Sociology.

Lombroso as an Alienist \L'CEuvre Psychiatrique de Lombroso\. {Rev. de
Psychiat., Feb., 1914.) Genil-Perrin, G.

Lombroso had intended to write a treatise on the “Insane Man.”
His daughter, Dr. Gina Lombroso, has carried out his wish, so far as it
is now possible, by bringing together in one volume under the title of
L' Homme Aliene, all the scattered psychiatric essays published by her

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father between 1859 and 1909. On the basis of this book, Genil-Perrin
discusses Lombroso’s place in psychiatry.

A simple idea presides over Lombroso’s psychiatric work—the
relationship of the psychic to the physical—but until that idea prevailed
mental medicine could not achieve emancipation. That emancipation
came in 1859—the year in which Lombroso’s work opens—with the
publication of Morel’s famous Traite. Lombroso’s work has seldom
been judged with impartiality. The exaggeration of his ideas, their too
rapid vulgarisation, their distortion by ignorant adepts, provoked in the
scientific world an attitude of unjustified repulsion. Certainly in
Lombroso’s work we must know how to test and to modify. His im¬
petuous spirit was always pushing ahead without waiting to elaborate
His writings are essays rather than well-digested treatises. His
southern ardour was rebellious to the labour of verification. He always
started from facts, but from those facts he rose too rapidly to generalisa¬
tions which sometimes revealed genius, and were sometimes illusory,
but were always hazardous. This romantic violence, these revolutionary
utterances, necessarily aroused controversy. It was by a sudden
intuition on a cold December morning in 1870, when examining a
brigand’s skull, that Lombroso threw out his atavistic theory of crimi¬
nality, and in 1864, at a happy turn of his fortune at Pavia, that in a
succession of sleepless nights he sketched his Man of Genius. Such
enthusiastic outbursts injured Lombroso's reputation in the scientific
world, while they brought him a popular notoriety which was equally
injurious.

Yet I^ombroso’s work revealed new conceptions, which, in spite of
their boldness, were fruitful. We must remember the dates of his
writings, and that we cannot expect of precursors the precise methods
of later workers. Lombroso had the defects of his qualities, but the
qualities were there.

The book which Dr. Gina Lombroso has edited is of much interest
for alienists, although that interest is now mainly historical. A chief
merit of it, however, is that it shows the psychiatric importance of
Ivombroso’s work as a whole. His criminological work has received
more attention, but we must not forget that he was above all an
alienist, and that it was from the study of insanity that he proceeded to
the consideration of the largest sociological questions.

It was Lombroso’s fundamental doctrine that man is an organic whole,
with all the parts intimately bound together. Man’s intelligence and
instincts and appetites are not confined to special seats ; they dwell in all
his viscera, tissues, and functions. There is no anomaly or disorder on
the physical side which is not reflected on the psychic side, no disorder
on the psychic side but has an echo on the physical side. Thus the
insane must be studied in their totality, and it was so that Lombroso
attempted to study them, “as objects of natural history,” biologically in
the first place, and finally psychically. To classifications Lombroso
assigned no great importance. He regarded them as purely con¬
ventional groupings, only useful for convenience in study. Therefore,
to prevent confusion, they should be changed as little as possible. He
considerably changed one category, however, that of epilepsy, and when
we realise to what an extent he enlarged it—inserting hysteria, circular

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insanity, moral insanity, obsessions, and much else—it is not surprising
that he often came on the traces of “ epilepsy.”

Prof. Bianchi, in a preface to L'Homme Aliine, compares Lombroso’s
work to Charcot’s. Genil-Perrin remarks that this is true in a different
sense from that probably meant by Bianchi. The work of Charcot and
his pupils is now largely out of date, because their interpretations were
too hasty and sometimes forced. But the method of Charcot, the
application to nervous pathology of clinical and anatomical investigation,
is immortal. It is the same with Lombroso. The theories are often
hazardous, but the method remains. When we place Lombroso’s work
in the right light, “ that work may well seem to us one of the greatest
scientific events of the nineteenth century.” Havelock Ellis.

The Personality of the Accused in the New Code of Penal Procedure [La
personality del giudicabile nel ttuovo Codice di Procedura Pena/e].
(Arch, di Anthrop. Critn., May-June , 1914). Bianchi.

In this address, delivered at the inaugural meeting of the Society di
Anthropologia, Sociologia e Diritto Criminale, Prof. Bianchi discusses
the present state of the relation between biological science and the
criminal law, with special reference to the changes which have been
recently introduced into the Italian Code of Procedure. As a result of
these changes larger powers have been given to the courts to investigate
the mental condition of accused persons, and particularly of juvenile
offenders, and of offenders in whom there may be reason to suspect
the existence of insanity or mental defect. While welcoming this
reform as implying a partial recognition of the importance of the
biological factor in criminality, Prof. Bianchi expresses regret that the
legislature has not gone farther on this road, and has not boldly adopted
the doctrine that crime is always and in all cases a manifestation of
abnormality in the offender. This view he holds to be true not only of
the grosser and more primitive forms of delinquency, but also of the
subtle and ingenious frauds which constitute so important a feature of
the modern evolution of commercialism, and which, though not techni¬
cally coming within the reach of the law, imply in those who perpetrate
them a degree of egotism and moral defect that must be regarded as
pathological. This “ frock-coated delinquency ” has not, he considers,
received the attention which it merits at the hands of criminologists,
and he suggests it as a rich field for investigation, though admitting that
it is hardly possible as yet to indicate very clearly the lines on which its
scientific study is to be approached. Even in the cruder forms of
criminality it is not always easy to furnish definite proofs of the patho¬
logical constitution of the offender, and biological science has still
much to do before it can establish its predominant claim to decide on
the treatment of the individual criminal. That it must assert, and will
eventually establish, that claim Prof. Bianchi is convinced, and for this
reason he is no advocate of compromise between the legal and the
biological conceptions of crime. However much the opposition between
these two points of view may be masked by such concessions to modem
ideas as are embodied in the new Italian code, no final solution of the
difficulty is possible until the principles and methods of biology have

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permeated legal theory and practice. As a striking instance of the
divergence between the two attitudes, the author points to the reluctance
of the lawyer to accept the principle of the indeterminate sentence for
recidivist criminals, though this principle must be admitted as an
inevitable inference from the doctrine which considers criminality as the
expression of a vice of organisation. Meanwhile we are traversing a
period of confusion of thought, and are attempting to unite the incom¬
patible principles of the classical and the biological schools of crimino¬
logy, with the result that, while we have very properly abandoned the
old punitive methods, we have failed to adopt in their place the effective
measures which science indicates for the protection of society against
the criminal. W. C. Sullivan.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly General Meeting of the Association was held at No. 11,
Chandos Street, London, W., on Tuesday, November 24th, 1914, Dr. David G.
Thomson, President, in the chair.

There were present: Drs. T. S. Adair, Fletcher Beach, E. H. Beresford, F.
St. John Bullen, R. B. Campbell, J. Chambers, R. H. Cole, M. Craig, H. Devine,
A. R. Douglas, T. Drapes, J. H. Earls, C. F. Fothergill, B. Hart, G. H. Johnston,
J. Keay, N. T. Kerr, P. W. MacDonald, H. J. Mackenzie, W. F. Nelis, D. Orr,
G. E. Peachell, J. G. Porter Phillips, G. M. Robertson, R. G. Rows, J. Noel
Sergeant, G. E. Shuttleworth, R. P. Smith, J. G. Soutar, J. B. Spence, R. H. Steen,
R. C. Stewart, H. Wolseley-Lewis, and M. A. Collins (Hon. Gen. Sec.).

A letter of regret was received from the Honorary Treasurer, Dr. Hayes Newing¬
ton, regretting his enforced absence from the meeting on account of illness.

Present at the Council Meeting (November 24th, 1914): Drs. D. G. Thomson,
T. S. Adair, E. H. Beresford, R. B. Campbell, J. Chambers, R. H. Cole, M. A.
Collins, H. Devine, T. Drapes, A. R. Douglas, B. Hart, J. Keay, N. T. Kerr, H. J.
Mackenzie, W. F. Nelis, G. M. Robertson, R. G. Rows, J. Noel Sergeant, J. G.
Soutar, R. H. Steen, H. Wolseley-Lewis.

Minutes.

The President said that the minutes of the May quarterly meeting were pub¬
lished in the Journal for July, and those of the August special meeting in that of
October. A special meeting was held in September, and he would ask the General
Secretary to read the minutes of that meeting. Both special meetings were in
connection with the revision of the Articles of Association.

The minutes were duly approved and signed.

Resolution of Council respecting the Royal Asylums of Scotland.

The President asked the Secretary to read a resolution which was passed at the
meeting of the Council held that day.

The Secretary read the resolution, as follows : .

“ The Council of the Medico-Psychological Association of Great Britain and
Ireland direct the attention of the Association to the hardships of the Staffs of the
Royal Asylums of Scotland, which are not included under the benefits of the
Asylum Officers’ Superannuation Act; and recommend that letters be written to
the Managers of the Royal Asylums, the Scottish Board of Control, and Sir John
Jardine on the subject.”

The resolution was unanimously adopted.

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Election of Candidates as Members.

The following gentlemen were balloted for and duly elected ordinary members :
Crosthwaite, Frederick Douglas, M.B., Ch.B.Edin., D.P.H.Cantab.,
Assistant Physician, Pretoria Mental Hospital, South Africa.

Proposed by Drs. A. D. Pringle, H. Egerton Brown, J. M. Moll.
Manifold, Robert Fenton, M.B., B.Ch.Dub. Univ., Senior Assistant Medical
Officer, Denbigh Asylum, N. Wales.

Proposed by Drs. James F. Gemmel, J. G. Blandford, R. Stewart.
Russell, William, M.B., Ch.B.Edin., Dipl.Psych.Edin., D.T.M.Edin.,
Assistant Physician, Pretoria Mental Hospital, South Africa.

Proposed by Drs. A. D. Pringle, H. Egerton Brown, J. M. Moll.

Watson, Harry Christian, M.B., Ch.B., B.A.O., R.U.I., Assistant Physician,
Pretoria Mental Hospital, South Africa.

Proposed by Drs. A. D. Pringle, H. Egerton Brown, J. M. Moll.

Alteration of Bye-law 55.

The President said that this was a formal matter, namely, a suggestion by the
editors that the Bye-law be altered so that the words " next after the Annual
Meeting ” be deleted, and the words “ in January ” be inserted in their place.

The Secretary said that the Bye-law, No. 55, directed that the lists of Officers,
Trustees, and Members of the Association should be published in the number of
the Journal next after the annual meeting. That was a very inconvenient require¬
ment, and he believed it had never been carried out; and now that the bye-laws
were being reprinted, it was thought better that the bye-law should accord with
the custom, namely, to publish the list in the January number, which would be
convenient for all concerned.

The alteration was approved.

The Question of the Holding of Meetings during thf. War.

The President said that this matter was considered by the Council that day,
and it was thought desirable to hold the quarterly meeting, as usual, in February
next; but, instead of, as had been hoped, holding it in Birmingham, to which city
the Association had been kindly invited by the Visiting Committee and Medical
Superintendent of Bromsgrove Asylum, it would be held in London, and without
any festive accompaniments.

This was agreed to.

Injury to Dr. Hetherington.

The President said it had just come to his knowledge that a colleague, Dr.
Hetherington, of one of the Irish asylums, had been seriously assaulted by a
patient, and he asked if Dr. Drapes could give any information about the distressing
occurrence.

Dr. Drapes said he could not give much information. It was on the day of the
Irish meeting that he heard about the occurrence, for Dr. Hetherington intended
being present at the meeting, but a wire was received stating that he had been
attacked by a patient and wounded, but it was hoped that the wound was not
serious. Two days ago he heard from Mrs. Hetherington that the doctor was
going on well, and that serious results were not anticipated, which he was sure the
meeting would be glad to hear.

The Secretary was directed to send a letter of condolence to Dr. and Mrs.
Hetherington.

The Late Dr. Sidney Nelson Crowther.

The Secretary sa'd he had received an intimation that Dr. Sidney Nelson
Crowther, who recently was appointed Superintendent of Netherne Southern
Counties Asylum, and who had enlisted as a motor-cyclist scout, was recently
killed in action. He felt sure that the Association would wish to send a message
of sympathy to his relatives. Dr. Crowther had served in a similar capacity
in the South African War.

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The President moved that a letter of condolence be sent to the relatives of the
late Dr. Sidney Crowther, expressing the Association’s sorrow at the sad event.

Approved.

The Late Dk. Harold Shaw.

Dr. Percy Smith said the Association would be sorry to learn of the death,
after a short illness, of Dr. Harold Shaw, of the Isle of Wight Asylum.

The President moved that a letter of condolence be sent to the relatives of Dr.
Harold Shaw.

Approved.

The Fate of the Belgian Asylums.

The President said he had been asked by several lay people in his neighbour¬
hood whether he could tell them what had happened to the Belgian asylums during
the terrible devastation which had accompanied this war. He was unable to answer
the question, and he wondered whether any of his colleagues could give any
information on the subject. Gheel, the celebrated colony asylum, was somewhat
to the north of the track of invasion, and hence it had possibly not suffered much.
But he thought there must be several asylums in the centre and the south of
Belgium which had suffered. One of the daily papers contained a story of one,
but it was very incomplete.

No members present, however, were able to supply any information, and the
matter dropped.

The meeting then terminated.

REVISION OF BYE-LAWS.

A Special Meeting was held at 11, Chandos Street, London, on Tuesday,
September 22nd, 1914.

Present: Drs. Fletcher Beach, Bower, Cole, Elgee, Hart, Lord, Ogilvy, Stans-
field, Stilwell, Stoddart, Soutar, and M. A. Collins (Hon. Gen. Secretary).

In the absence of the President and ex-President, who both sent letters of
apology, Dr. J. G. Soutar was elected to the chair.

The Chairman explained that the Companies Act required a second special
meeting to confirm the resolution passed at the special meeting held on August
24th last.

Dr. Fletcher Beach proposed and Dr. Stansfield seconded the confirmation of
the resolution (see p. 694, vol. lx). Carried.

The meeting then terminated.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held by the
kind invitation of Dr. Graeme Dickson at Wye House, Buxton, on Thursday,
October 22nd, 1914. Dr. Dickson presided.

Members present .— Drs. G. Dickson, E. S. H. Gill, R. W. D. Hewson, G. R.
Jeffrey, R. Legge, S. R. Macphail, J. M. Mathieson, J. Middlemass, R. C. Stewart,
W. Vincent, and T. S. Adair (Hon. Divisional Secretary).

Regrets of inability to attend were received from the President (Dr. Thomson),
Drs. Douglas, Pierce, and Johnson (Harrogate).

The minutes of the last meeting were read and confirmed.

Richard R. Kirwan, M.B., B.Ch., B.A.O., R.U.I., Assistant Medical Officer,
W. R. Asylum, Menston, Leeds —proposed by Drs. Edgerley, Walker, and Adair—
was unanimously elected an ordinary member of Association.

On the proposal of Dr. Macphail, seconded by Dr. Vincent, Drs. McDowall,
Pierce, and Street were unanimously re-elected to form the Divisional Committee
for the next twelve months.

Dr. R. C. Stewart then read a short paper on “ Restraint in Mental Disease,’’
with the object of opening up a discussion on this subject. He dealt with restraint

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in its widest sense, and considered briefly mechanical restraint, the use of single
rooms, the question of locked doors in asylums, treatment by sedatives, etc. He
was of opinion that everything that took away the feeling of restraint tended to
benefit the patient.

The paper was followed by an interesting discussion, in which every member
present took part, and various opinions were expressed on the numerous points
raised.

One speaker held very strong opinions about mechanical restraint, and thought it
never ought to be used, or only in very rare cases. He considered it had a bad
moral effect on the nursing staff. Seclusion appeared to him only a lesser evil,
and he did not like using drugs. It had always been a difficult problem with him
to decide what was the best treatment for perverse old chronic patients.

A distinction was drawn between acute and chronic cases, and it was generally
agreed that the difficulty of finding a suitable means of restraint lay in the case of
the latter.

The use of verandahs, and sleeping out of doors, for noisy patients were con¬
sidered beneficial.

The various forms of sedatives in use were referred to, and special reference was
made to the use of bromides.

The limitation of airing courts by unclimbable fencing, and the old question of the
locked asylum door were to some extent dealt with.

It was suggested that too many single rooms were provided in many asylums,
and that they might be better used as “ privilege ” rooms than for the isolation of
noisy patients.

Dr. Stewart replied, after which a hearty vote of thanks was accorded to Dr.
Dickson for his kind hospitality, also to the Manager of the Buxton Baths, the
Secretary of the Devonshire Hospital, and the Buxton Gardens Committee, for the
kind facilities extended by them to the members. The Secretary was instructed
to convey to them the thanks of the meeting.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division was held, by the courtesy
of Dr. Rawes and the Governors, at St. Luke’s Hospital, on Thursday, October 8th,
1914.

Among those present were: The President (Dr. D. G. Thomson), Drs.W. H. Bailey,
F. Beach, D. Bower, A. H. Boyle, R. Brown, P. E. Campbell, J. Chambers, M. A.
Collins, A. R. Douglas, F. H. Edwards, C. F. Fothergill, R. W. Gilmour, J. L.
Gordon, D. Green, W. J. H. Haslett, H. E. Haynes, F. P. Hughes,'G. VV. B. James,
R. Armstrong-Jones, G. E. Miles, Sir James-Moody, N. Navarro, H. H. Newing¬
ton, H. J. Norman, N. H. Oliver, G. E. Peachell, W. Rawes, Sir George Savage, J.
Scott, G. E. Shuttleworth, R. Percy Smith, R. .H. Steen, H. F. Stilwell, R. J.
Stilwell, J. Turner, F. Watson, W. R. Watson, S. A. K. Wilson, and J. Noel
Sergeant (Hon. Divisional Secretary).

Expressions of regret at inability to be present were received from several
members.

At half-past one, the members were entertained to luncheon, at the conclusion of
which Dr. Thomson proposed the health of the host—Dr. Rawes—which was drunk
with acclamation.

The Meeting of the Divisional Committee was held at 2.15 p.m.

Parts of the Hospital were inspected by the members.

The General Meeting was held at 3.30 p.m., Dr. Thomson in the Chair.

The minutes of the last meeting, having been printed in the Journal, were taken
as read and confirmed.

Dr. T. E. K. Stansfield was elected a Representative Member of the Council for
the remainder of the year 1914-15.

The following gentlemen were elected Ordinary Members of the Association :

Victor Lindley Connolly, M.B., B.Ch., B.A.O., Assistant Medical Officer, Colney
Hatch Asylum, New Southgate, N. (Proposed by Drs. F. J. Gilfillan, Samuel
Elgee, and John Macarthur.)

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I915O

Samuel Edgar Martin, M.B., B.Ch.Edin., Barrister-at-Lavv, Senior Assistant
Medical Officer, St. Andrew’s Hospital, Northampton. (Proposed by Drs. B.
Rambaut, N. R. Phillips, and J. Noel Sergeant.)

Ernest Haines Walker, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
East Sussex County Asylum, Hellingly. (Proposed by Drs. F. R. P. Taylor, J. N.
Greene Nolan, and W. Rees Thomas.)

Gwilym Ambrose Williams, L.R.C.P.Lond., M.R.C.S.Eng., Pathologist and
Assistant Medical Officer, East Sussex County Asylum, Hellingly. (Proposed by
Drs. F. R. P. Taylor, J. N. Greene Nolan, and W. Rees Thomas.)

The invitation of Dr. Sergeant to hold the next Spring Meeting at Newlands
House on April 29th, 1915, was accepted with much pleasure.

Dr. H. J. N orman then read his paper on “ Friedrich Nietzsche ” (see p. 64).
Dr. Thomson voiced the appreciation of the Meeting for this interesting com¬
munication. Sir George Savage and others also spoke.

At the conclusion of the Meeting the members were entertained to tea.

The members dined together in the evening at the Cafe Monico.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of this Division was held at the University, Bristol, on
Thursday, October 22nd, 1914. Dr. Aveline presided.

Members present: Drs. Adams, Bullen, Brown, Cole, Lavers, McBryan, Nelis,
Perdrau, Read, Thomas, Wigan, White, and the Hon. Divisional Secretary (Dr.
Blachford). Dr. Macphail was present as a visitor.

Letters of regret for non-attendance were read from the President (Dr. Thomson)
and Dr. MacDonald.

The minutes of the last meeting were read and signed.

The Hon. Divisional Secretary was nominated for re-election.

Drs. Lavers and Pope were nominated for election as Representative Members of
the Council.

Charles Williams, L.R.C.P. and S.E., L.S.A.Lond., Assistant Medical Officer,
The Warneford, Oxford—proposed by Drs. A. W. Neill,T. S. Good, A. McWilliam
—was unanimously elected an Ordinary Member of the Association.

The Spring Meeting was fixed for Thursday, April 22nd, 1915.

An interesting paper on “ Freud’s Interpretation of Dreams " (see page 17) was
contributed by Dr. Bullen, and Drs. Stanford, Read, and Cole took part in the
discussion which followed, and were replied to by Dr. Bullen.

The members afterwards dined together at the St. Stephen’s Restaurant.

SCOTTISH DIVISION. . .

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Royal College of Physicians, Queen Street, Edinburgh, on
November 13th, 1914.

Present: Sir Thomas Clouston, Drs. Dods Brown, Carswell, Cruickshank,
Chislett, Gostwyck, Hotchkis, Carlyle Johnstone, Keay, Kerr, Oswald, Orr,
G. M. Robertson, Ford Robertson, Ross, Maxwell Ross, Shaw, Sturrock, and
R. B. Campbell, Divisional Secretary.

Dr. Oswald occupied the chair.

The minutes of the last Divisional meeting were read and approved, and the
Chairman was authorised to sign them.

Apologies for absence were intimated from Dr. Thomson, President of the
Association, Drs. Yellowlees, Turnbull, Easterbrook, McRae, Mackenzie, Carre, and
Crichlow.

Before taking up the ordinary business of the meeting, the Chairman offered
the congratulations of the Division to Dr. Keay on his nomination as President¬
elect of the Association, and Dr. Keay thanked the Division for their kind
congratulations and good wishes.

The Chairman also referred, in suitable terms, to the recent resignation of
Dr. A« R. Turnbull from the Medical Superintendentship of Fife and Kinross

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District Asylum, and he considered that this event could not pass without the
Division recognising the long and valuable services which Dr. Turnbull had
rendered to the Scottish Division, and also his services in the interests of lunacy,
and at the same time expressing the hope that he would be long spared to enjoy
his well-earned retirement. It was unanimously resolved that the Secretary be
instructed to send an excerpt of the minutes to Dr. Turnbull.

The Business Committee was appointed, consisting of Drs. Carlyle Johnstone,
G. M. Robertson, McRae, Kerr, Orr, and the Divisional Secretary.

Drs. Neil T. Kerr and J. H. C. Orr were nominated by the Division for the
position of Representative Members of Council, and Dr. R. B. Campbell was
nominated for the position of Divisional Secretary.

The following four candidates, after ballot, were admitted to membership of the
Association:

(1) Alfred William Harper Cheyne, M.B., Ch.B., Assistant Physician, Royal
Asylum, Aberdeen. (Proposed by Drs. Reid, Alexander, and Campbell.)

(2) Thomas Chivers Graves, M.B., B.S., F.R.C.S.Eng., B.Sc., Assistant Physi¬
cian, Royal Asylum, Edinburgh. (Proposed by Drs. G. M. Robertson, Maxwell
Ross, and Henry Yellowlees.)

(3) Hugh Kirkland Shaw, M.B., Ch.B., Assistant Physician, Stirling District
Asylum. (Proposed by Drs. Campbell, Keay, and Gostwyck.)

(4) William John Tulloch, M.D., Director Western Asylums Research Insti¬
tute, 10, Claythorn Road, Glasgow. (Proposed by Drs. Oswald, Parker, and
Macdonald.)

Gram-negative Diplococci in Dementia Pr^ecox.

Dr. Ford Robertson read a communication on the "Gram-negative Diplo¬
cocci in Dementia Prtecox.” He stated that the question of these diplococci had
arisen in the course of a systematic investigation into the infective conditions
associated with dementia pratcox. He showed the characters of the bacteria of
this group obtained from the gums in eighteen cases of dementia prsecox, and
compared them with those isolated from the mouth or respiratory tract in eighteen
control ca$es. The main conclusion drawn from the investigation was that the
Gram-negative diplococci that abounded in the gums in many cases of dementia
prsecox were simply the Micrococcus catarrhalis, and the varieties of the Micro¬
coccus pseudocatarrhalis that were to be found with equal frequency in other
persons suffering from chronic catarrhal conditions of the respiratory tract. No
evidence had been obtained of the occurrence of any special Gram-negative diplo-
coccus, or of tissue invasion by any member of the group.

Interesting papers were contributed by Drs. Gostwyck and Maxwell Ross
on "Juvenile General Paralysis” and “The.Luetin Test in Parasyphilis” respec¬
tively.

A vote of thanks to the Chairman for presiding concluded the business of the
meeting.

IRISH DIVISION.

The Autumn Meeting of the Division took place on Thursday, November 5th,
1914, at the Royal College of Physicians, Dublin. Dr. T. Drapes was in the
chair. The other members present were: Drs. J. O'C. Donelan, Eustace, Gavin,
Greene, O'Neill, Rainsford, Redington, Rutherford, and Dr. Leeper (Div. Hon.
Secretary).

The minutes of the previous meeting were read and signed by the Chairman.

A letter from Mrs. Hetherington was read, informing the members that Dr.
Hetherington was unavoidably prevented from attending the meeting owing to his
having been attacked and wounded by a patient in his asylum. A telegram of
condolence was sent to Dr. Hetherington by the Chairman on behalf of the
meeting.

It was proposed by Dr. Rainsford and seconded by Dr. Greene, and passed
unanimously: "That this meeting of the Irish Division of the Medico-Psychological
Association begs leave to tender to their fellow-member, Sir John Lentaigne, the
expression of their most sincere sympathy with him in the great loss he has

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sustained by the death of his son, Lieutenant Victor Lentaigne, while serving with
the Expeditionary Force.”

Dr. Edward Joseph McKenna, M B., B.Ch., B.A.O., Assistant Medical Officer,
Carlow District Asylum, proposed by Dr. T. H. Greene, was balloted for and
unanimously elected an ordinary member of the Association.

Dr. J. O’C. Donelan read his paper, “ A Case of Recurrent Purpural
Eruption.” (See p. log.)

The Use of Hypnotics in Acute Mania.

Dr. Rainsford, in opening the adjourned discussion from the Summer
Meeting, said he was in many ways ill-equipped for introducing a subject so full
of interest, for he was one of the few asylum medical superintendents who had
never used any of the new hypnotics. He would speak of the subject under two
heads : (i) Drugs to produce sleep; (2) drugs to produce quiet. As regards the
first, probably nothing called for more anxious thought than the selection of a
suitable drug to produce sleep in any given case. Personally, he would say the
great desideratum was to procure for a patient a healthy sleep with the least
possible risk to the individual. As regards drugs of this class, he thought paralde¬
hyde best answered all the requirements, and he had many cases where prolonged
and hitherto intractable cases of insomnia had been cured. He started generally
with 5»j, gradually diminishing the dose. Trional, while it had many disadvan¬
tages, and was stated to cause nerve degeneration, was, in doses of 20-25 gr., very
useful as an occasional hypnotic, but should not be given to any case oftener
than once a week. Sulphonal he had not used for many years. He regarded
chloral as the best hypnotic, of all in suitable cases, as the sleep it procured was of
a very refreshing character. He found the combination known as the "three
fifteens” admirable, vis. 15 gr. chloral hydrate, 15 gr. potassium bromide, and
15 minims liq. opii sedativus (Battley). As regards opium as a hypnotic, he
would only say that, as a rule, it was a safe drug, but it must be given in a
sufficiently large dose, as too small doses only caused excitement. Veronal he
had only used in two or three cases and he knew nothing to commend it. As
regards the second head, he would like to say he was no advocate for the indis¬
criminate use of what might be termed "chemical restraint,” bat he freely
recognised that there were cases where it was necessary. For many years he had
been taught that half-ounce doses of tinct. hyoscyamus were very useful, and he
could testify to the excellent results from its employment, and he had never seen
any unpleasant after-effects, and an old medical superintendent used to say that
it made the patient so thirsty that one often got them to drink plenty of fluid
nourishment after it, which was an additional advantage. Hyoscin hydrobromate
he had found excellent in doses varying from up to T ‘ u gr., and in one case
which he related, when a dose of ^} tlj gr. was given, its beneficial results were
very striking. Morphia, hypodermically, was uncertain, and the dose must be
large to obtain good results. In one case he had given 1 gr. morph, hydro-
chlor. hypodermically before the patient was appreciably affected.

The Chairman (Dr. T. Drapes) said that all present must be interested in the
question of hypnotics, as a selection of a suitable hypnotic was a matter which had
to be decided daily.

Dr. Donelan said he had a great deal of experience of the use of hypnotics in
maniacal cases. He quite agreed with Dr. Rainsford that the combination of
chloral, opium, and bromide cannot well be surpassed. Prolonged restlessness
and sleeplessness seem to accentuate depressive delusions in melancholics. As
regards veronal, he once had a case which gave him great anxiety, in which a
moderate dose seemed to produce symptoms akin to suffocation; the patient
recovered, but he had since discontinued its use. He believed veronal had a
cumulative action, and he was averse to its habitual use in mental cases. He
mentioned some interesting cases of poisoning by veronal taken habitually by
persons suffering from the drug-habit.

Dr. O’Neill said he had a long experience of chloral when he was an assistant
at the Richmond Asylum. The dose given to excited patients was 30 gr. of
chloral and 30 gr. of bromide of potash, combined with Spis. Ammon. Aromat.,
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half at bedtime, and the remainder in three hours if necessary. He thought well
of veronal, and he considered paraldehyde the most suitable of all hypnotics, espe¬
cially if any cardiac trouble were present, its only objection being its odour and
taste.

Dr. Redington gave veronal frequently with excellent results, but, having seen
the accounts of inquests upon some cases of poisoning by the drug, he had now
discontinued its use. As regards suiphonal he had had a case in which, after a dose
of 30 gr., ataxic symptoms were observed.

Dr. Greene wished to say that when he was younger he had to work with a
physician who was very fond of what he might call “ grape shot ” prescriptions ;
prescriptions containing many sedative drugs: opium, chloral, bromide, gelsemi-
num, hyoscyamus, etc. He thought it was a matter of little importance in
chronic cases what sedatives were selected, so long as they were safe and did not
endanger life, but in acute cases the selection of a suitable hypnotic was all impor¬
tant. As a practical matter one was frequently obliged either to use hypnotics or
to use mechanical restraint, and as no one wished to imitate those who have gone
before us, and whose methods of treatment are now regarded as obsolete, they
were inevitably led to use hypnotics in the treatment of excited cases. As regards
their therapeutic action, other than as sedatives, they knew little. As regards veronal,
they know it is a compound of urea, and they also know that some people were
singularly affected by this substance ; and having regard to the existence of idio¬
syncrasy and intolerance of urea compounds shown in some cases, they did not
think they were justified in using veronal. Every practitioner knew all that is to
be known of opium and its compounds and its therapeutic value. He had the
greatest confidence in the combination known as the “ three fifteens,” viz.: 15 gr.
Battley’s solution, 15 gr. of bromide, and 15 gr. of hydrat of chloral. He believed
no patient ever died from this combination and these doses. He believed it was
perfectly safe in all cases, and no ill-results had ever occurred from its administra¬
tion in his practice. None had hitherto spoken of hyoscin ; he believed T ^j gr.
given in cases of acute mania gave placid rest. No one needed to be afraid of the
use of hyoscin properly given in suitable doses, and its advantage was markedly
beneficial by the muscular rest it secured for the patient. Mechanical restraint
he considered better than attendants, say, five or six, holding a patient, and in
extreme cases of excitement the patient must be paralysed by drugs to ensure
quiescence, the benefit of which was exceedingly doubtful.

Dr. Gavin said he had but once to resort to mechanical restraint in the treat¬
ment of a case of insanity. This patient was attempting self-mutilation—pulling
off his testicles. He found, however, that it was only necessary to get the
patient up and dressed in his trousers, which took the place of mechanical
restraint.

Dr. Rainsford asked Dr. Gavin if he had remarked in his experience that Irish
patients were more acutely excited and maniacal than English or Scotch ones.

Dr. Gavin replied that he found patients much less maniacal, and acute mania
much less severe in character, in Ireland, than in England or Scotland.

Dr. Donelan said that there were some cases where restraint might be justified,
but that restraint demoralised the staff of any asylum, and had a tendency when
once adopted to creep into an institution to its detriment.

Dr. Eustace said all were agreed as to the importance of the selection of a
safe hypnotic, and thought well of small hypodermics of morphine. He had
once given suiphonal in a 20 gr. dose through nasal tube in an obstinate case of
recurrent melancholia. This patient collapsed and nearly died, and on the
following day had hematoporphyrinuria, showing that some patients were singularly
susceptible to the drug.

Dr. Rutherford spoke favourably of paraldehyde, which produced sound sleep
in most cases when given in doses 5iss to jij.

The Chairman (Dr. T. Drapes) said he was glad to see that all the members
present had spoken of their experiences of hypnotics, and the discussion had been
useful and interesting. He spoke of the moral effect of modern asylum treatment,
and said it largely did away with the necessity for mechanical restraint. He men¬
tioned a case of self-mutilation of extreme gravity, in which occasional restraint
was of undoubted benefit. Restraint was more largely used in old days probably
for one reason, because physicians had not the choice of sedative drugs which we

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have to-day. He next reviewed several drugs in use as hypnotics, and spoke
highly of his experience of hyoscin. He had a sort of paternal interest in this
drug, as he believed he was the first to use it, and recommend its employment, in
Irish asylums. Dr. Daniel had read a paper at the annual meeting on the use of
hyoscin, but in the cases described, rather heroic doses were used. He (Dr.
Drapes) never gave more than T ^;j gr. for an initial dose, and seldom over 3*5 gr.
at any time. Sulphonal he used frequently, and it had been a favourite remedy of
Dr. Clouston, who thought it raised the spirits and promoted cheerfulness, in
melancholics, and at Morningside many years ago it had even been described as
“ smiling powder” when given in such cases. This good result had not, so far as
he was aware, been observed by others in similar cases. In his experience veronal
did not produce unfavourable results. Luminal he had recently tried and found
most efficacious. Omnopon he also found of use, and in his hands it had pro¬
duced no unpleasant after-effects. He had, however, not made sufficient trial of
it as yet to enable him to form a decided opinion as to its merits. The prolonged
warm bath and wet-pack were amongst the most valuable adjuncts to sedative
treatment. In conclusion, he said that papers read at their meetings upon research
work, valuable as they were, could only be discussed by experts in research, but all
could join in discussions upon clinical subjects, and he considered the Division
owed much to Dr. Rainsford for having introduced this discussion, and he hoped
others would bring forward subjects of clinical interest more frequently at their
meetings.

Dr. Rainsford, in replying, spoke favourably of the administration of hyoscin
in doses of ^ gr. and mentioned a case when this treatment was eminently
successful, and discussed the relative merits of trionai and sulphonal as hypnotics ;
he thanked the meeting for the very kind way in which they had all joined in the
discussion he had introduced.

Dr. Greene having pointed out that owing to the war attendants had volunteered
and gone to the front in the interests of the nation, and were thereby prevented
from presenting themselves for the preliminary examination for the nursing
certificate, requested the meeting to secure, if possible, that these attendants
should be allowed their examination. After discussing this matter, the following
resolution was proposed by Dr. Adrian Greene, seconded by Dr. Eustace, and
passed unanimously: “That we, the Irish Division of the Medico-Psychological
Association, reauest the Educational Committee to recommend the Council
in the case of those attendants who were attending the lectures being delivered
to qualify them for entrance for the preliminary examination for the Medico-
Psychological Association’s Certificate, and who are at present serving in either the
navy or the army, to sanction their being allowed the examination, provided that
they be recommended for the privilege by their resident medical superintendent,
and that they have served the necessary period of years in an asylum.

The Hon. Secretary was directed to forward the resolution without delay to the
Hon. Secretary of the Educational Committee of the Association.

It was proposed by Dr. Donelan, seconded by Dr. Rainsford, and passed
unanimously: "That the best thanks of the Division be tendered to the President
and Fellows of the Royal College of Physicians for the use of the rooms of the
College for meetings of the Division."

A cordial vote of thanks to the Chairman terminated the proceedings.

LONDON COUNTY COUNCIL (').

Mental Deficiency Act.

Mental Deficiency Act, 1913 —Administrative Difficulties.

The Mental Befu iency Act has now been in force for upwards of seven months,
long enough to enable-some-conclusions tobe drawn as to its value, and to indicate
some of its difficulties. These latter are conspicuous, and we think the time has
come wh ;n the more important difficulties with whi< h the local authority is faced
in discharging the duties placed upon it by the Act shouldibe brought specifically
to the-Council's notice.

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NOTES AND NEWS.

[Jan.,

The earliest date allowed by the Act for the appointment by the Council of a
Committee for the purposes of the Act, as required by Section 28, was 1st April,
1914, and there was therefore no period of anticipatory preparation possible,
within which accommodation might have been secured, and other necessary
administrative machinery might have been set up ready for the commencement of
the Act. The Council began its work as the local authority under the new Act
subject to considerable disadvantage in that it was faced with demands for action
in a number of individual cases which called for prompt action, if any, while the
means for handling cases, and even the principles upon which cases should be dealt
with, were to a large extent absent or indeterminate. The Act left many vital
points to be settled by regulations and rules which were not issued until dates
subsequent to that upon which the Act came into force, and then only in a pro¬
visional form. The regulations made by the Board of Education have since been
confirmed, but the important regulations made by the Home Secretary under the
Act, which are essential to the administration of the Act, still remain provisional
and subject to amendment. Upon some points which the Act leaves for definition
by regulation, regulations have not yet been made, e.g., the transfer and discharge
of patients front institutions. It will be seen, therefore, that the Council's task
has been, and continues to be, performed under difficulties occasioned by doubt as
to how effect should be given to certain provisions of the Act, added to which are
further difficulties due to the obscurity of the Act itself upon certain points.
Nevertheless, much of the procedure necessary for the administration of the Act
has been established, and work is being carried on as far as possible upon definite
lines.

Cases which can be dealt with.

The Act strictly limits the cases which may be dealt with to four classes, via.,
idiots, imbeciles, feeble-minded persons and moral imbeciles, and the definition of
each class which the Act gives provides that the particular degree of defectiveness
specified must have existed from birth or from an early age. It has been found
that this stringency of definition excludes from the operation of the Act many
cases of which particulars are communicated in the expectation that they will be
dealt with. But there is a further considerable limitation of the Council’s powers
over those cases which do come within the scope of the Act, for of such cases,
apart from those notified by the local education authority, and those who have come
within reach of the law in certain specified ways, the local authority has an
obligatory duty to deal only with those who are found neglected, abandoned, or
without visible means of support, or cruelly treated. The greatest difficulty has
been found in many cases, which seemed to call for action by the local authority
on all other grounds, in finding that there has been " neglect ” or absence of
41 visible means of support” within the meaning of the Act. For instance, the
parent of a defective child has given, and is prepared still to give to the child as
long as it remains at home, the best care and attention in his power. The child
does not lack food or clothing. At the same time the parent, who cannot afford to
provide institution care at his own cost, feels that institution care is needed in the
child’s interests. Such a case seems to be one in which the local authority ought
to act. The difficulty has been partly solved by concluding that the word
" neglected ” used in the Act must cover cases where, without wilful omission, the
care and accommodation provided, which might be adequate for a normal person,
are inadequate for one who is defective; in other words, that neglect may be
constructive as well as positive. This has enabled action to be taken in a number
of cases.

Ascertainment of Cases.

Information as to cases of alleged defect has been received from various sources.
Parents and relatives of persons supposed to be defective have applied for advice
or assistance; Poor Law officers have given notice of a few cases, and particulars
of several have been communicated by charitable societies, and persons interested
in the care of the feeble-minded. But the majority of the cases considered so far
have been those notified by the local education authority for the reasons specified
in Section 2 (2) or on other grounds, those of which notice has been received front
the police, and those undergoing imprisonment, as to which two medical certificates

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of defect have already been given to enable the Secretary of Stale, under Section 9,
to order the transfer of the cases from prison to institutions for defectives, and as
to which the Board of Control have made inquiry whether the local authority is
prepared to deal with them, and as to their character, antecedents, and home
surroundings.

The first duty of the local authority (Section 30^) is to "ascertain what persons
within their area are defectives subject to be dealt with ” under the Act otherwise
than at the instance of a parent or guardian, that is (a) under an order made by a
judicial authority upon a petition (Section 5) presented by a relative or friend or an
authorised officer of the local authority, or ( b) under an order of a court of com¬
petent criminal jurisdiction (Section 8), or (c) under an order of the Secretary of
State (Section 9). The duty of ascertainment involves the medical examination of
cases of which notice is received (but not, presumably, if they have already been
certified for the purposes of an order under Section 9), and, if they are found to be
defective within the meaning of the Act, further inquiry as to home circumstances,
etc., to enable a decision to be made whether as defectives they are “ subject to be
dealt with.” The provisional regulations issued by the Secretary of State deal at
some length with the nature of inquiries which should be made, which are to
extend to the family history, and are to be made under the directions of a medical
officer. A register of cases “ ascertained ” has to be kept. We are appending to
this report a statement of cases of which such information has been received, which
shows that of these cases a large proportion has been found either to be not defec¬
tive within the meaning of the Act, or, being defective, not subject to be dealt with
under the Act. The duty of ascertainment is very important and really difficult,
and it is not rendered easier by the fact that the local authority has been expressly
warned by the Home Office that it has no right to institute " domiciliary visitations
without the consent of the occupiers, or to carry out inquiries in other ways which
might reasonably be regarded as inquisitorial and objectionable.” Evidently,
therefore, the local authority is expected to proceed with caution in the ascertain¬
ment of cases.

The duty of ascertainment alone, apart from other duties under the Act, imposes
a considerable burden of detail work upon the staff at our central office, engaged
primarily for lunacy work, and upon the staff in the public health department who
are entrusted with duties under the Act, and the volume of work is greatly dispro¬
portionate to the number of cases which, in the result, have actually been dealt
with.

Consent of the Parent necessary to an Order for a Defective to be dealt with.

fn cases in which, after ascertainment, it has been decided that petitions for
orders for detention in institutions shall be presented to a judicial authority, further
difficulty may arise because the written consent of the parent or guardian has to
be given to the making of an order, unless the judicial authority considers that the
consent is unreasonably withheld. If consent is withheld the difficulty of deter¬
mining whether there is neglect, already referred to, may be increased and it may
not be possible to deal with some cases which in their own and the public interests
probably should be dealt with. In the first case dealt with under the Act by
petition the mother’s consent was withheld, and the judicial authority, after very
careful consideration, felt that he could not pronounce the withholding to be
unreasonable. A second petition, however, was presented to another judicial
authority, who took a different view, and an order for the defective to be sent to an
institution was ultimately made.

Liability of Local Authority to take action.

There has been much difficulty in some cases in determining as to the liability
of the Council or other local authority to take action. An order sending a defec¬
tive to an institution, or placing him under guardianship at the cost of a local
authority, has to specify the authority in question, which by Section 43 (1) is defined
to be “the council of the county or county borough in which he resided.” A
question has been raised as to the meaning of the word "resided," because in the
following Section 44, “ place of residence " in case of doubt is construed to mean
the county or county borough “ in which the person would, if he were a pauper, be

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deemed to have acquired a settlement within the meaning of the law relating to
the relief of the poor.” It seems open to doubt whether residence should in every
case be determined on the strict law of settlement, or whether a wider and more
general interpretation is to be placed upon the word " resided,” leaving resort to
Poor Law settlement only in cases where there is doubt as to place of residence in
the ordinary non-tcchnical acceptation of those words. Inquiry as to the settle¬
ment of every case which appears subject to be dealt with will increase enormously
the work to be done under the Act. Reference to other local authorities has
been made in some cases of which information has been given to the local
authority for London. In the case of a girl brought before one of the Metro¬
politan police magistrates on a criminal charge, and dealt with by the] magistrate
as a defective, the question has been raised whether the Council should be held
liable to deal with the defective, who appears to be settled in Kent. The magis¬
trate, however, on the ground that the defective had committed her offence in
London, and was homeless within the London area, held that the London County
Council was prima facie responsible for the maintenance of the defective in an
institution, and made an order sending the defective to a certified institution,
eaving the Council to take steps within three months to secure the transfer of
liability to another local authority.

Contributions to Expenses of Maintenance of Cases dealt with.

Where orders are made for cases to be dealt with at the Council's expense,
inquiry has to be made as to the means of the parents or other relatives, and,
wherever possible, arrangements for contribution by the relatives in relief of the
Council’s expense have been made. In some cases, judicial orders directing con¬
tribution have been obtained.

A ccom modal ion.

Brief comment should he made here upon the steps which have been taken for
the provision of accommodation for defectives by the Council. It has been felt
that until the scope of the Act is somewhat more clearly ascertained, it would not
be proper that the Council should embark upon the provision of specially-built
institutions, but inquiry has been made as to properties which could be taken on
lease, and adapted at small cost for temporary use. Many properties have been
inspected, but few have appeared suitable for use as accommodation for cases of
mental defect. The Council, however, has decided to purchase one property, the
mission schools at Streatham, for use in the first instance for defective females of
certain classes, and as a place of safety and receiving home to provide accommo¬
dation for some seventy cases. Another property is receiving consideration with a
view to a lease, and we contemplate the use of the old industrial school at Brent¬
wood, which is already the property of the Council, for male cases of defect. Th>-
only accommodation actually in use, so far, is what has been provided by means of
arrangements with various voluntary agencies.

Cases of which Information is received from the Police.

Special difficulties have been experienced in connection with the procedure for
dealing with cases of which information is received from the police, and cases in
prison where action under Section 9 is proposed, and with cases between the ages
of seven and sixteen.

Section 8 of the Act provides that on conviction of certain offences by a Court
of Criminal Jurisdiction a person proved to be defective may be dealt with by the
Court, which may direct that a petition may be presented for the case to be sent to
an institution or placed under guardianship, or may itself make an order sending
the case to an institution or placing it under guardianship. The Court has to be
satisfied of the defect on medical evidence, and the section places upon the police
the duty of bringing before the Court such evidence as may be available. The
police, also, when it appears that a person charged with an offence is defective,
have to communicate with the local authority, presumably in order that the local
authority may ‘‘ascertain” the case, and may have an opportunity to make repre¬
sentations to the Court if it appears that the case is not subject to be dealt with at

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its expense. Particulars of many cases of alleged defect have been received from
the Metropolitan Police, and, except in a few instances, have been examined by
the Council’s medical officer as part of the duty of ascertainment, and in order to
safeguard the Council’s interests. Many of the cases have been found not to be
defective within the meaning of the Act. The examination having been made,
however, it is apparently expected that the Council’s officer will assist the Court
with evidence as to the mental condition, and the Board of Control have asked
whether, in all cases where alleged defectives are charged with offences, the Council
will be willing on application by the police to provide medical evidence. We have
suggested that if this were agreed to the police should defray the expenses of the
witnesses, but there seems to be difficulty as to this. The Board of Control, how¬
ever, intimate that as “ ascertainment ” is an obligatory duty of the local authority,
and the medical examination of cases of which notice is given by the police is a
necessary part of this duty, they would be able to defray half the expenses of such
examination. This question is still engaging attention. There is a further purely
administrative difficulty to be borne in mind in this connection, occasioned by the
burden of work which is likely to be imposed upon the Council's officers if they
have to examine every case of alleged defect which comes before a "court of com¬
petent jurisdiction,” and by the fact that cases not infrequently come before different
courts at the same hour.

The cases of which information is received from the police are amongst the most
difficult of those with which the Council is expected to deal, and the problem of
finding suitable accommodation for such cases, in the absence of any provided
specially by the Council, is at present acute. Many of these cases are habitual
prostitutes, of whose moral improvement there seems small prospect, and practically
all the accommodation for fallen defective women which is available under contract
arrangements is confined to those of comparatively improvable mental type who
are susceptible of moral benefit. Negotiations, however, are being pursued for
accommodation for this particular class.

Defectives in Prison.

As regards defectives already in prison, who it is proposed shall be transferred to
institutions for defectives by orders made by the Secretary of State under Section 9
of the Act, the procedure hitherto has been for the Board of Control to intimate to
the Council that two medical certificates have been given upon which the Secretary
of State is satisfied of the existence of defect within the meaning of the Act.
Apparently, therefore, no further duty of " ascertainment ” as to the existence of
mental defect is expected of the local authority in these cases—in fact, this view
has been expressed to the Board of Control by the Prison Commissioners—but the
Board of Control inquire in each instance whether the local authority is prepared
to provide for the defective under the Act, and if so in what manner, and ask for a
report from the local authority as to “the character, antecedents, and home
surroundings” of the defective to enable the Secretary of State to judge of the
expediency of dealing with the case under the Act. Prosecution of inquiries upon
these points involves a great deal of work and much time, for which there is little
result to be shown. The Council has not at present accommodation suitable for
these prison cases, though it has been found possible to send a few of the younger
cases to accommodation available under contract, but for the great majority of
cases the Council has been obliged to say it is unable to make any provision. For
cases of dangerous or violent propensities the State is liable to provide accommo¬
dation, and of the cases as to which the Board of Control have made inquiry, some,
at least, have appeared to be subjects for a State institution. Such an institution
is understood to be in course of provision by the Board of Control, but has not yet
been brought into use.

We have been informed that the Board of Control receive from the Home Office
communications about a great number of defective prisoners concerning whom they
are at present refraining from writing to the local authority, as they realise the diffi¬
culty occasioned, at present, by lack of accommodation. The need for providing
for this class of case is, however, being urged, and apparently the prisons may be
expected to be a source whence many cases subject to be dealt with at the Council’s
expense will come.

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NOTES AND NEWS.

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It has been stated that the Council is not expected to arrange for further medical
examination of prisoners who have already been certified to the satisfaction of the
Secretary of State to be defective. Inquiry, however, has to be made of some of
these cases to ascertain what are their character and antecedents, and in the course
of such inquiry, made by the Council's medical officer, the opinion sometimes has
been formed that the case is not actually defective within the meaning of the Act.
The question of the existence of defect “ from birth or from an early age,” already
referred to, occasions great difficulty in these as in other cases. Doubtless, with
time and wider knowledge, there will be established some common ground for
decision upon this matter.

Defective Children .

Cases of mental defect between the ages of seven and sixteen present special
difficulties of their own. The duty of “ ascertainment ” of all such cases, referred
to in the Act as “ defective children,” is by Section 30 of the Act expressly
removed from the local authority, and imposed upon the local education authority,
which in London operates through the Council’s Education Committee. It is
enacted further that “ the local authority shall have no duties as respects defective
children except those whose names and addresses have been notified to them by
the local education authority ” under the provisions of the Act. Such notification
is possible (Section 2 (2)) in the case of defective children : (i) who have been
ascertained to be incapable, by reason of mental defect, of receiving benefit or
further benefit in special schools or classes ; (ii) who cannot be instructed in a
special school or class without detriment to the interests of other children ; (iii) as
respects whom the Board of Education certify that there are special circumstances
which render it desirable that they should be dealt with under the Act by way of
supervision or guardianship ; or (iv) who, on or before attaining the age of sixteen,
are about to be withdrawn or discharged from a special school or class, and in
whose case the local education authority is of opinion that it would be to their
benefit that they should be sent to an institution or placed under guardianship.
The "special school or class” referred to is a special school or class within the
meaning of the Elementary Education (Defective and Epileptic Children) Act,
1899. The local education authority has communicated particulars of some cases
of defective children who are undergoing detention at the Council’s expense in
industrial schools or reformatories (which are not “ special schools or classes”),
the term of detention being about to expire on the child reaching the age of
sixteen, where it is thought desirable that there should be continued detention after
the age of sixteen in an institution for defectives, and where the Secretary of State
might make an order for transfer to such an institution under Section 9 of the
Mental Deficiency Act. The Secretary of State's order could be made only while
the case is undergoing detention, ».<?., before the child reaches the age of sixtten.
The order, moreover, could be made only on an institution the managers of which
are willing to receive the case, and in the absence of accommodation specially
provided by the Council the managers of any other institution obviously would be
willing to receive only those cases for which the Council would be willing to pay.
But the local authority has no obligatory duty to perform with regard to a defective
child under the Mental Deficiency Act unless the case has been “ notified” by the
local education authority, and notification, which can be made only on one or other
of the grounds specified in Section 2 (2), as already quoted, has been found in
some instances very difficult. As a result, some cases have passed the age of
sixtr en without an order having been made, and, having then been discharged from
the industrial school or reformatory, it becomes impossible for the local authority
to deal with the defectives unless they are found subject to be dealt with as
neglected, abandoned, without visible means of support, cruelly treated, or again
within reach of the law. This condition of affairs might, in many cases, lead to,
unfortunate results.

The difficulty which has been felt hitherto has lain in the fact that, as the local
authority has no obligatory duty to perform with regard to defective children
unless the children’s cases have been notified, any action taken under voluntary
powers (which exist) would have to be taken at the sole cost of the Council without
aid from the Treasury grant, which is to be administered by the Board of Control
since the Board have intimated that the grant will be applied to defray half the

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cost of the performance by local authorities of those duties which are obligatory.
It is now understood, however, that the Treasury grant may be applied to some
extent to defray half the cost of the performance of voluntary duties in cases such
as those now under discussion. We are awaiting further information from the
Board of Control upon this matter, but in the meantime it may be pointed out that
a means of escape possibly lies in this direction from the dilemma with which the
education authority and the local authority have been faced in their joint desire to
deal with certain cases where action is very necessary but far from easy.

( l ) Report (Abstract) of the Asylums and Mental Deficiency Committee sub¬
mitted to and received by the Council on December 1st, 1914.

A HOMICIDAL ATTACK ON DR. HETHERINGTON, MEDICAL
SUPERINTENDENT, DISTRICT LUNATIC ASYLUM, LONDON¬
DERRY.

At a special Court in the Boardroom of Derry Asylum, before Colonel

J ohnstone, R.M., a patient, named Thomas Baird, was charged by District
nspector M’Hugh with assaulting and stabbing Dr. Charles E. Hethcrington,
Resident Medical Superintendent, occasioning him grievous bodily harm.

Dr. Hetherington stated that while returning on the afternoon of November 3rd
from the female department to the office he met defendant in the passage. When
witness was passing he said something about getting out, and witness replied it
would be all right. Witness proceeded, but observed defendant, who was then
behind, raising his hand. Witness caught defendant’s hand. They had a struggle,
and witness felt him cutting his throat. They both struggled out to the yard,
defendant still cutting at witness's throat. Witness called for help, and an
attendant came to his assistance. Witness did not remember getting free from
defendant, but he remembered returning to the passage holding his neck, which
was bleeding badly. Dr. Watson, who was then called, attended to witness’s wounds.
Witness did not see anything in defendant’s hands.

Michael M’Laughlin, an attendant, stated that he saw the doctor and defendant
struggling on the ground, and went to the doctor's assistance. Witness pulled
defendant away from the doctor, who was underneath. Defendant was striking at
the doctor's neck and face, and, as witness went forward, he observed him throw
away something like a cutter-knife. When the doctor was being taken away
defendant then tried to kick him.

James M’Laughlin, the head attendant, said accused, who had been in his
charge prior to the attack, had gone down the passage to wait on other patients
going to dinner. Witness went to fetch a patient whom Dr. Hetherington wanted
to see, and on returning, his attention was attracted by the struggle between the
doctor and the patient in the yard. Witness assisted the other attendant in freeing
\ the doctor, and afterwards found the knife, which Baird had thrown away.

Dr. Watson, Senior Medical Assistant, said after the attack Dr. Hetherington
was brought to him bleeding profusely. Describing the doctor's injuries, witness
said there were two incised wounds on the right side of the throat about an inch
long, and on the right lower jaw there was an incised wound about two inches long.
This cut was through the facial artery, and caused most of the bleeding. On the
left side there was an incised wound about two inches long, running parallel to the
lower jaw. There were several smaller abrasions about the temples, and the collar
and necktie which the doctor was wearing were cut in several places. On the
middle and ring fingers of the right hand there were incised wounds, and also
incised wounds on both wrists and in the middle of the left hand. The doctor
was suffering very much from shock, and witness would say that his life was in
danger. The wounds described could have been caused by the instrument pro¬
duced. Accused had been a patient in the institution for four years. %

The R.M. returned accused for trial at the Assizes .—Belfast Evening Telegraph,
November 26th, 1914.

At the Assizes, the jury found that the prisoner was insane, and he was ordered
to be detained during the Lord Lieutenant's pleasure.

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LIBRARY OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.

The Library is open daily for reading and for the purpose of borrowing books.
Books may also be borrowed by post provided that at the time of application three¬
pence in stamps is forwarded to defray the cost of postage. Arrangements have
been made with Mr. H. K. Lewis to enable the Association to obtain books from the
lending library of that firm should any desired book not be in the Association's
Library.

The Library subscribes to the following journals:

Journal of Abnormal Psychology.

Journal of Nervous and Mental Diseases.

American Journal of Insanity.

Journal de Psychologie Normale et Pathologique.

Zeitschrift fur die gesamte Neurologic und Psychiatric.

Psychoanalytic Review.

Review of Neurology and Psychiatry.

The following books have recently been added to the Library:

Psychoanalysis. —Brill.

Outlines of Psychiatry. —W. A. White.

Dementia Prcccox. —Meyer and Jelliffe.

Three Contributions to Sexual Theory. — Freud. (Translation by Brill.)

Histological Studies on the Localisation of Cerebral Function. —Campbell.

The Integrative Action of the Nervous System. —Sherrington.

The Psycho-Pathology of Everyday Life. —Freud. (Translation by Brill.)

Fifty-sixth Annual Report of the Commissioners in Lunacy for Scotland.

Members are reminded that they are entitled to receive any of the journals by
post in accordance with the Library Committee’s scheme of distribution. Members
wishing to avail themselves of this scheme should communicate with the Secretary,
specifying the journal or journals which they require.

The Secretary would be glad to receive from members suggestions as to books
suitable for addition to the Library.

Applications for books should be addressed to the Resident Librarian, Medico-
Psychological Association, 11, Chandos Street, Cavendish Square, W. Other com¬
munications should be addressed to under-mentioned at Long Grove Asylum,
Epsom, Surrey. Edward Mapother,

Hon. Sec. Library Committee.

OBITUARY.

Dk. Harold Bailey Shaw.

We regret to have to record the death of Dr. H. B. Shaw, who was for many
years Medical Superintendent of the Isle of Wight Co. Asylum, and a respected
member of the Association since 1891.

The deceased gentleman was the son of the late Dr. William Shaw, of Hampstead,
London. He was educated at Epsom and Sidney College, Cambridge. He
graduated in arts at Cambridge, taking First Class Honours in the Natural Science
Tripos of 1880. He became M.B., B.C. in 1884, and D.P.H. in 1890, at the same
University.

His first years were devoted to physiology, physics, and organic chemistry at
Charing Cross Hospital School. He was then Medical Officer, Smallpox Camp,
Darenth, and Resident Clinical Assistant at Winson Green Asylum, Birmingham.
For two years he was Assistant Medical Officer at Gloucester Co. Asylum, leaving
there for the Hampshire Co. Asylum, where he remained for six years as senior.

When the Isle of Wight Asylum was opened he became its first medical super¬
intendent, which position he occupied for eighteen years—until his death.

Oti the last day of a fortnight's holiday he was taking at Bournemouth he had an
attack of cerebral ha:morrhage, from which he succumbed within a few hours on
September 28th, 1914.

He was fifty-six years of age and was entitled to take his pension from last
November. He was buried at Gatcombe Church near the Asylum on October 2nd,
>9M.

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Dr. Sidney Nelson Ckowthek.

We regret to report the death of Sidney Nelson Crowther, Senior Assistant and
Superintendent-Elect of the Surrey County Asylum, Nethenic, killed in actiun
whilst carrying despatches near Armentieres on October 18th. Dr. Crowther
received his medical education at the Westminster Hospital, becoming
M.R.C.S.Eng. and L.R.C.P.Lond. in 1903. He took up asylum work at
Brookwood, and on the completion of the new asylum at Netherne he was
transferred there as Senior Assistant Medical Officer.

He was a brave gentleman, and a thorough sportsman in the best sense of the
word, and possessed a strong and charming personality which endeared him to all
who knew him.

He served in the South African War as dresser, and at the outbreak of the
present campaign sought his Committee’s sanction to volunteer again, this time
ns a motor despatch rider. The spirit of patriotism prompted this, notwithstanding
the fact that he had just been appointed successor to the retiring Superintendent,
whom he persuaded to continue in office until his return from service in H.M.
Forces.

He will be greatly missed by a wide circle of friends, especially those at
Netherne, where his popularity amongst patients and staff was unbounded.

On November 1 ith, a memorial service was held at the Asylum Chapel, Netherne.
The Rev. F. H. Roberts, the Asylum Chaplain, officiated, together with the Rev.
E. Bingham. The service was widely attended. The official account of Dr.
Crowther's death is as follows:

“ Information supplied by Officer Commanding Second Signal Troop as to
death of S. N. Crowther.

“The deceased was killed by shell fire whilst taking a despatch at Le Piniett,
east of Armentieres. He was buried in a garden of a small cottage in the above-
named place, and at the first opportunity it is intended to place a cross over his
grave, bearing the inscription : ‘ In loving memory of Corporal Crowther, Royal
nginee rs. Died 18th October, 1914. R.I.P.’”

Dk. Robert Reid Alexander.

It is with the deepest regret that we have to record the death, suddenly from heart
disease, of Dr. Alexander, late of Hanwell Asylum, on November 14th, 1914. The
deceased gentleman was born in Aberdeen, and received his medical education at
the Aberdeen University, where he graduated M.B., C.M., in 1869, taking his
M.D. in 1878.

His asylum career commenced at the Aberdeen Royal Asylum, where he was an
Assistant Medical Officer, and from whence he occupied a similar position at the
Bucks County Asylum. In 1873 he joined the medical staff of the Middlesex County
Asylum, Hanwell. From the position of Assistant Medical Officer he became, in
1888, Medical Superintendent of the Male Department, and finally, on the abolition of
the dual control at the end of 1891, sole Medical Superintendent. He was transferred
to the London County service upon the London County Council taking over
Hanwell Asylum in April, 1889. He retired in 1905, after thirty-two years’ service,
and was granted by the Asylums Committee a maximum retiring allowance.

His disposition was of the kindest and most sympathetic imaginable, and he was
always eager to befriend the friendless and help those in need. He was a broad¬
minded man, who never shirked his responsibility, and was courageous to a degree.

His memory for faces and names was remarkable, and he always had a personal
knowledge of every patient resident, by all of whom he was held in high respect
and affection. He was an indefatigable worker—toiled early and late, and seemed
to be able to do almost without sleep.

He was a good French scholar, and later, after retirement, Esperanto became an
all absorbing pursuit which he could speak fluently, and as a labour of love trans¬
lated into that language part of the New Testament. He also interested himself
in Braille work for the blind.

At Hanwell, an institution teeming with great traditions and memories of the
past, he was actively associated with most of the stagi s of its evolution to its
present position of eminence.

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His passing away will call to the minds of his numerous past colleagues and
friends many treasured recollections, and in the halls and courts of old Hanwell,
where his life was spent unselfishly and ungrudgingly in the service of others, the
memory of his genial and commanding presence and strong individuality will
never fade.

At the funeral, which took place quietly on November 18th at Golders Green
Crematorium, the London County Asylums Committee was represented by its
clerk, Mr. H. F. Keene, and Hanwell Asylum by Dr. Daniel, Mr. Martin, engineer,
and others.

“ Night brings out stars as sorrows show us truth.’’

Dr. Edward Charles Spitzka.

Hy the death of Dr. Edward Charles Spitzka, medical science has lost one of its
most brilliant votaries, and the New York Neurological Society one of its oldest
and most productive members.

He was born in New York City on November 10th, 1852. His father, a man
of broad attainments and large reading, was early involved in the Revolution in
Germany in 1848, whose cause he actively espoused, and on account of which he
emigrated to America. Shortly after his arrival with his wife, the son was born.
The parents sent their boy to the New York public schools, No. 35, whose
11 principal " was the well-known Thomas Hunter.

The son made rapid strides in his studies, and at a very early age entered the
College of the City of New York. He soon evinced a definite preference for the
natural sciences, and became especially interested in the subjects of biology,
geology, and palreontologv. These studies so fascinated him that he determined
to take up the study of medicine, and became a student in the medical depart¬
ment of the University of the City of New York. Even while pursuing his
medical studies he kept up his reading in the subjects previously mentioned.

After his graduation from medical school he proceeded to Germany,and settled
in Leipsic. There he came under the influence of Wagner, von Coccius, His,
Wunderlich, and Thiersch. After leaving Leipsic, he went to Vienna, where he
met the man who had the greatest influence in determining his future career,
namely, Meynert, under whom he accumulated a wealth of anatomical, physio¬
logical, and pathological knowledge which became the foundation of the most of
his subsequent claims to fame. In some respects Spitzka resembled his great
teacher and master, Meynert, especially in the possesssion of a vast fund of general
information, and particularly in a thorough acquaintance with the facts of com¬
parative anatomy. While in Vienna he also became interested in the subject of
embryology, human and comparative, whose study he followed under Professor
Schenk, who appointed him, with the consent of the authorities of the university,
an assistant to the chair of embryology. Spitzka remained abroad altogether
three years, after which he returned to the city of his birth.

Shortly after his return in 1876, he began the collection of whatever neurologic
pathologic and anatomical material he could obtain, chiefly from the public and
ti e private asylums of the city and its environs, and commenced his anatomical,
neurological, and psychiatrical investigations.

His was a dominating, overpowering personality. Endowed by nature with an
unusual capacity for work, gifted with the most extraordinary powers of analysis,
possessing a memory so retentive that it seemed almost supernatural, and withal,
a fluency of thought and facility of speech, he was equipped with advantages
v. hose like is seldom possessed by any single individual. To these attributes was
brought an exceptionally creative and vivid imagination, which suggested and
initiated cf great deal of the work of his active mind. His facility in writing even
eclipsed the ease and fluency of his speech.

He was a seeker after truth, and content with investigations only after they had
satisfied all of the requirements of established facts, logic, and pure reason.

He was interested in many fields of human thought and knowledge, and
generously contributed to both. Nobody except those who had been intimate
with him could realise the extent and breadth of this knowledge. Possessing the
use of many languages, thoroughly acquainted with history, knowing the literature
of the people whose language he spoke, expert in all the branches of biological

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173

science, he was easily one of the most versatile members of the medical pro¬
fession.

This versatility shows itself in his writings, which embrace the departments of
history, biology, palaeontology, criminology, forensic medicine, and neurology,
including neuro-anatomy, neuro-physiology, neuro-pathology, and psychiatry.

His work will be judged by medical men chiefly on account of his contributions
to the last-mentioned subjects. These contributions to medical sciences were
very numerous, many containing original discoveries and new view-points. His
published writings in these subjects alone numbered over two hundred. These
embody many entirely new discoveries and original points of view that made the
sciences of neurology and psychiatry distinctly the gainer.

In neuro-anatomy, his name will be perpetuated by his discoveries, and it will
live as long as the science. He was also the first to introduce into America an
adequate conception of the scope of a true psychiatrical science. Up to that time
the study of mental disease in this country was based on an empirical foundation
for the most part; the pathological basis of the subject was but imperfectly known
or even studied in general. It was to his influence that the more serious study of
the subject was taken up. It did not take long before his reputation became a
national one, due in some measure to the fact that the trial of the assassin of
President Garfield was then imminent. There was an almost universal cry for
the sacrifice of the assassin, Guiteau. Spitzka, with a courage which was the
result of a nature which could not tolerate falsehood, and convinced of the fact
that the murder was the work of an insane man, did not hesitate to give his
testimony to that effect. This event in his early life—he was at that time only
twenty-nine years old—is mentioned, because it indicates the most dominant
characteristic in his organisation, viz., the desire for truth, no matter what the
consequences. One can imagine the courage he possessed, when one becomes
acquainted with the fact that his life was threatened, that he received letters
warning him that if he gave testimony to the effect that Guiteau was insane his
own life would be sacrificed.

The great influence which he exercised in the field of psychiatry was best shown
in his book, a Manual of Insanity, which went through two editions. The
book embodied the study of all the large amount of pathological material which he
had collected. Part of this had been previously used by him in the preparation
of an essay, which had earned for him the W. and S. Tuke Prize, given through
the British Medico-Psychological Association, and which had been open to inter¬
national competition. This essay was entitled “ The Somatic ^Etiology of
Insanity.”—(Abstract from an appreciation by Dr. N. E. Brill before the New York
Neurological Society, April 7th, 1914, fount. Nerv. and Ment. Dis., August,

1914).

NOTICES BY THE REGISTRAR.

Dates of Examinations.

Certificate in Psychological Medicine and Gaskell Prise. —July, 1915.

Nursing Certificate.

Preliminary examination .... Monday, May 3rd.

Final examination.Monday, May 10th.

Schedules for the Nursing Certificate examinations can be obtained from the
Registrar and must be returned to him duly completed not less than four weeks
prior to the date of examination.

Essays for the Bronte Medal should reach the Registrar on or before June 14th.
Papers for competition for Divisional Prizes should reach the Registrar on or
before June 1st.

Full particulars of all examinations can be obtained from the Registrar, Dr.
Alfred Miller, Hatton Asylum, Warwick.

NOTICE OF MEETINGS.
Quarterly Meeting, May 18th, 1915, London.

South-Eastern Division. —April 29th, 1915, Newlands House.

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South-Western Division. —April 22nd, 1915.

Northern and Midlands Division. —April , 191 3 > Harrogate.

Scottish Division. —March 19th, 1915.

Irish Division.— April 15th and July 1st, 1915.

APPOINTMENTS.

Bartlett, George Norton, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Medical Supers
intendent at the Exeter City Asylum.

Coombes, Perceval Charles, M.R.C.S., L.R.C. P.Lond., Medical Superintendent,.
Surrey County Asylum, Netherne.

Cormac, H. Dove, M.B., M.S.Madras, Medical Superintendent of the Cheshire
County Asylum, Macclesfield.

Ferguson, J. J. Harrower, M.B., Ch.B.Edin., Medical Superintendent at Fife and
Kinross Asylum, Springfield.

Lewis, Edward, L.R.C.P.&S.Edin., L R.F.P.S.Glasg., Medical Officer under the
Mental Deficiency Act to the Glamorganshire County Council.

Moon, G. B., L.R.C.P.&S Edin., L.R.F.P.S.Glasg., Second Assistant Medical
Officer at the Surrey County Asylum, Netherne.

Peachell, George Ernest, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, Isle of Wight Asylum.

Rivers, William Gregory, M.B., Ch.B.Edin., Senior Medical Officer and Deputy
Medical Superintendent to the Cornwall County Asylum, Bodmin.

Walford, Harold R. S., M.R.C.S., L.R.C.P., Second Medical Officer, Kent
County Asylum, Barming, Maidstone.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland .]

No. 253 [To*",'"] APRIL, 1915. VOL. LXI.

Part I.—Original Articles.

The Diagnosis and Treatment of Parenchymatous
SyphilisSf) By F. W. Mott, M.D.Lond., LL.D.Edin.,
F.R.S., Pathologist to the London County Asylums.

Gentlemen, —It is customary for the President of a Section
to open the proceedings by an address, but I feel that it would
serve a more useful purpose if I opened the discussion on the
diagnosis and treatment of parenchymatous syphilis by giving
an account of the observations which I have been making
regarding the microscopic and bio-chemical pathology of tabes
and general paralysis ; for it is by an understanding of the
pathological processes underlying these diseases that we are
able to make a correct diagnosis, and prevent their occurrence
or arrest their progress. My personal experience of the effect
of treatment is somewhat limited as compared with that of
many of those who are to take part in the discussion, and
therefore I shall especially devote my attention to the observa¬
tions which have been made in the Pathological Laboratory of
the London County Asylums.

The Discovery of the Spirochcetes in the Brain.

The discovery of the spirochaete in the brains in twelve cases
out of seventy by Moore and Noguchi, confirmed by further
LXI. 12

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observations and by other workers, has not only forged the last
link in the chain of evidence necessary to show that syphilis
is the essential cause of general paralysis and tabes, but it has
made it necessary to regard the pathology of these diseases in
a new light, and in future to speak of them as “ parenchymatous
syphilis.” Noguchi later examined 200 brains from cases
dying from general paralysis, and twelve spinal cords from
tabes dorsalis. He has obtained positive results in 2 5 per cent.
of the cases of general paralysis, whilst only one of the twelve
cases of tabes gave a positive result. He regards general
paralysis as a chronic parenchymatous encephalitis.

Soon after Noguchi published his paper a number of
observers—Berial, Jakob, Levy, Marinesco and Minea, Marie,
Levaditi and Banchowski, Mott, Ranke, Schmorl, Vers£—con¬
firmed the existence of spirochaetes in the brains of paralytics.
Very soon Forster and Tomasczewski, followed by Noguchi,
demonstrated the presence of spirochaetes in small cylinders of
brain removed during life by the Neisser-Pollak puncture
method.

The Existence of the Spirochcetes in the Central Nervous System
in Relation to the Pathology of Parenchymatous Syphilis.

I have examined now a series of 100 brains of patients who
during life presented the clinical symptoms and signs of general
paralysis, and in 66 per cent, of the cases spirochaetes have been
found by examination with dark-ground illumination, confirmed
by staining films by the Fontana silver method. If the film
be fixed by the same method the spirochaetes can be readily
stained by methyl violet, polychrome blue, or by Giemsa method.
Forster and Tomasczewski say they find difficulty in staining
by Giemsa. It is impossible to examine the whole of the
cortex in a search for foci of spirochaetes, and naturally the
question arose whether clinical or pathological indications
would afford a clue to the most likely situations to find the
organism in a series of brains. There is first the probability
of association of active multiplication of the specific organism
with production of toxins and the onset of seizures. If the
seizures are unilateral it is probable the poison is being pro¬
duced in the hemisphere opposite to the side on which the
epileptiform convulsions are occurring. Next it occurred to

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me that the most likely situations to find the spirochaetes would
be those regions which show the earliest naked eye evidence of
the disease, namely, the pole and mesial surface of the frontal
lobe, and the frontal end of the limbic lobe ; these are regions
where congestive venous stasis and adherence of the lepto-
meninges are first apparent. It was soon found that by far the
most satisfactory method, both for rapidity and certainty of
demonstrating the existence of spirochaetes, was to make an
emulsion from the cortex of the brain, from the regions men¬
tioned, by rubbing up in a glass mortar a little scraping of the
grey matter with normal saline or Ringer’s fluid, and then
examining with the dark ground illumination. The spiro¬
chaetes can easily be seen on the dark ground ; and in a num¬
ber of instances where the brain was removed soon after death
more or less active movement could be observed. Cases with
marked cortical wasting, according to our experience, yielded
far less satisfactory results than recent cases, with little apparent
cortical wasting. Sometimes the organisms were found in a
quarter of an hour, sometimes only after a day’s search. They
seem to be present only in small foci, for not infrequently a
spot a few millimetres away from that in which the organism
had been found would yield negative results. The great diffi¬
culty of this investigation is that the search for the organism is
like looking for the proverbial needle in the haystack ; not
finding does not imply non-existence. We have never been
able to find the spirochaetes once in brains of patients dying
with other forms of insanity. Very often a preparation of brain
emulsion showing spirochaetes has been sealed round with
paraffin, and kept for days and observed at intervals ; numbers
of other micro-organisms have been found, but the spirochaetes
can still be seen. Forster and Tomasczewski found spirochaetes
twenty-seven times in sixty-one cases examined by Neisser-
Pollak puncture. In eleven the spirochaetes were as abundant
as in primary syphilis or congenital syphilitic lesions. In
sixteen cases they had to seek for hours and make many pre¬
parations. I have had a similar experience in the examination
of brains obtained post mortem. Their experience does not
quite accord with mine, for they remark that in simple demential
forms spirochaetes are as numerous as in cases where convulsive
seizures have occurred.

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Experimental Observations.

Noguchi inoculated into the testicles of thirty-six rabbits
the emulsion of six different specimens of brains of general
paralytics in the fresh state. At the end of ninety-seven days in
one case, and 102 days in the other, a small but typical indu¬
ration of the testicle and scrotal skin occurred. In the first
case the spirochaetes were few ; in the second they were abun¬
dant. Steiner claims to have produced in rabbits experimental
syphilis of the nervous system by using albinos, and by sensi¬
tising the animals with several intravenous injections of spiro-
chaetal testicular emulsion.

It is interesting to note how slow was the development, as
compared with the transmission by infection, made with material
obtained from a chancre, secondary lesion, or even a gumma ;
in the latter case the lesions appear after an interval of four to
six weeks—rarely two months elapse. Dr. Topley, aided by a
grant from the British Medical Association, endeavoured at my
suggestion to produce lesions in monkeys by injection of emul¬
sions of brain material in which I had found spirochaetes. His
efforts to produce infection were unsuccessful, whether the
material was injected into the brain or into the testicle. After
the publication of the important results to be now described
further research was abandoned.

Forster and Tomasczewski commenced their experiments in
June, 1913, so that they have been in progress nine months,
yet the results have so far been negative. Seeing that these
observers have used material obtained from brains during life,
and have exercised great precautions in their experiments, the
results obtained, although negative, are of very great importance
and value. Briefly stated, their experiments were the following :
Puncture material from brains of 53 paralytics were ino¬
culated into the testes of 60 rabbits, and 1 5 of these animals
lived over two months without any signs. It may be remarked
that Noguchi’s rabbits did not develop any signs in the testes
for 98 days, so that their results do not prove much.
Of 13 apes, however, inoculated in the eyelid with material
proved to contain spirochaetes, 5 died 61, 82, 86, 88, and
90 days after inoculation, but 7 have been over four months
under observation. Small nodules in the lids have been
observed in some of these animals four to five weeks after

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inoculation, but most careful research of a serous exudate
obtained from the lesion showed no spirochaetes. Intracerebral
inoculation was also unsuccessful. Observations were made
upon 40 rabbits and 17 apes for over four months. The
failure to infect monkeys with this material containing abun¬
dance of active spirochaetes is remarkable when we consider
that material of tertiary syphilis, in which it is difficult to find
spirochaetes, when inoculated usually produces infection.

Evidence in Favour of a Biological Change in the Spirochcetes.

It may be assumed, therefore, that this evidence favours the
view that there may be a biological difference between the
spirochaetes of general paralysis and tabes and those of primary
syphilis. The successful inoculation experiments of Noguchi,
Berger, and Steiner with a long incubation period supports this
conclusion. No one has been inoculated by handling brain
material of general paralysis, and the unsuccessful attempts to
infect monkeys, even when the material has been obtained from
the living body and immediately introduced into the body of
the animal, shows that the organism has undergone a biological
change. “ Still it is unexplained when, where, and how this
change has come to pass.” The cause of the long incubation
period, the typical course, and the peculiar characteristic patho¬
logical anatomy of this disease in relation to the spirochetal
infection, therefore, is of fundamental importance in the study
of syphilis of the nervous system in relation to prevention and
treatment. The biological change may be considered from
several points of view.

(1) The spirochaetes that cause the primary lesion are
biologically modified. They may have been attenuated in their
virulence by the widespread use of mercury ; if this hypothesis
be accepted, they may be spoken of as mercury-fast organisms
which have acquired a resistance by natural selection, either
by the acquirement of a habit of secreting themselves in the
central nervous system, where metallic poisons such as arsenic,
antimony, and mercury do not penetrate, or the attenuation has
been effected by a diminished chemiotropism to these poisons.

(2) It is not the spirochaetes that have changed, but the
fluids and tissues of the body. The charts of conceptions of
mothers of sixty cases of juvenile general paralytics show that

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following miscarriages, abortions, stillbirths, anti deaths in early
infancy are children, who, at puberty, or in early adolescence,
develop general paralysis. One half of these paralytic children
had signs on the body of congenital syphilis ; the remainder of
the sixty had no definite signs, although the history of the fate
of conceptions was conclusive evidence of infection of the
mother. In the greater number of cases the mothers were
unaware of the fact that they had had syphilis.

These facts seem to show that antibodies are being con¬
tinually formed in the body of the mother which kill off the
organisms as fast as fresh broods are formed ; but with each
development of spirolytic antibodies the organism is modified
as regards virulence, so that the tissues of the living offspring
are eventually able to cope with the disease by the same process
of production of antibodies and spirillolysis. It may chance,
however, as fresh bodies are formed, that some of the organisms
get lodged in the central nervous system and penetrate the
parenchyma ; it is true that they may be weakened and
attenuated organisms, but under normal conditions they would
find a safe resting-place there, because the cerebro-spinal fluid
which irrigates the whole substance of the central nervous
system contains no leucocytes or bactericidal substances. Just
as the pneumococcus or tubercle bacillus may remain quiescent
in the body until some depressing or devitalising condition
arises when they take on active growth, so it is possible that
the spirochaete, or a granule antecedent form, may remain latent
for many years in the central nervous system before taking on
active development and killing its host.

The Existence of Spirochcetes in Parenchyma of the Central Nervous
System in relation to the Morbid Histological Changes.

It must be admitted that it is the toxins produced by the
multiplication of the organisms which produce the inflammatory
parenchymatous reactions of the tissues. In general paralysis
there is a chronic meningo-encephalitis, but the whole cerebro¬
spinal axis suffers in some degree sooner or later, whereas in
tabes dorsalis this is an elective action, and the disease is
limited to histological changes affecting the posterior spinal
protoneurons.

l'he experimental observations of Orr and Rows show that

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PRINCETON UNIVERSITY

1 9 1 5-1

BY F. W. MOTT, M.D.

i 8 i

toxins generated outside the spinal canal can pass up the nerves,
and cause degeneration of the posterior columns only. This
is the course of the lymph stream. Ehrmann found spirochaetes
in the nerve bundles near the primary sore ; they were lying in
the lymph spaces of the perineurium and endoneurium. It is
probable, therefore, that infection of the central nervous system
may occur by the lymphatics of the nerves. It may also
occur by the perivascular lymphatics. We have no evidence
to show that the spirochaete is in the posterior spinal ganglia,
and the one case out of twelve of Noguchi’s in which he found
the organism in the spinal medulla may have been a case of
tabo-paralysis. Moreover, it is difficult to believe that the
spirochaetes in tabes exist in the spinal medulla in all cases, as
is the case, in all probability, in the brain of the paralytic. If
the spirochaete were present in the medulla in tabes we should
expect a more generalised reaction in the medulla, as it is
unlikely that an organism with independent movement would
not penetrate the grey matter and give rise to a myelitis, as we
know it does in general paralysis where there is a general diffuse
encephalitis. Now this difference in the pathogenesis of the two
diseases is of very considerable importance, not only in regard
to the comparative pathology of the two diseases, but also in
regard to the explanation of the fact that treatment in tabes
is satisfactory in many cases, whereas in general paralysis it is
altogether unsatisfactory.

The more rapid destruction of the nervous elements in general
paralysis may be correlated with the constant presence of the
organism in the central nervous system, and the generalised
effect of the virus on the whole central nervous system, especially
the brain. What part does this virus play in the production of
the characteristic perivascular infiltrations with lymphocytes and
plasma cells also of the neuroglia proliferation ? Similar perivas¬
cular appearances and neuroglia proliferation occur in gumma¬
tous brain syphilis, general paralysis, and in sleeping sickness.
In gummatous brain syphilis, whether localised or diffuse,
although there may be profound vascular changes causing
interference with the blood supply, yet there is not the profound
general wasting of the nervous system, and of the cortex cerebri
in particular, as occurs in all cases of advanced general para¬
lysis, the wasting being in direct proportion to the decay and
destruction of nerve-cell and fibre systems. In sleeping sick-

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ness, where the perivascular infiltration and neuroglia prolifera¬
tion are as marked as in advanced general paralysis, we do not
find a proportional wasting of substance, and neuronic decay
and destruction.

The Biological Nature of the Spirochceta Pallida.

The similarity of the lesions produced by trypanosome infec¬
tions to those of syphilis was used as one argument among
others in favour of the Spirochceta pallida being a protozoon.
However, there is a tendency now for biologists, and others
who have studied the question, to regard spirochaites as more
akin to bacteria than protozoa. Mr. Clifford Dobell, of the
Imperial College of Science, who has long studied the biology
of spirochaetes, has come to this opinion. He does not think
it is proved that they multiply by longitudinal division, neither
does he think there is reliable evidence of the existence of a
spore form. Meyrowski claims to have observed true lateral
branches of the spirochaetes in tissues, and in cultures which
offer to him the best proof of their plant-like nature, and he
gives photographs of the same. Many of the appearances he
describes are similar to those which I have seen in emulsions of
the brain in general paralysis, but which Mr. Dobell considers
as artefacts of degenerative forms. Meyrowski denies the
possibility of these being involutional forms. I think the
argument that the tissue reaction corresponds in trypanosome
disease and syphilis is not valid, because the tubercle bacillus
causes endothelial and lymphocyte proliferation. The malarial
parasite, which is a protozoon, lives in the blood circulation,
and gives rise to no such chronic lymphatic reactions as syphilis,
neither do trypanosome infections while the organism exists
only in the blood stream. It is remarkable that in spite of the
fact that the brain harbours the spirochaetes in all cases of
general paralysis, the lymph glands in the neck are apparently
not affected ; the only tissue that shows a fairly frequent definite
syphilitic lesion is the aorta, and definite nodular fibrosis I
found to occur in 40 per cent, of 400 male paralytics ; this
lesion of the aorta occurs as frequently in tabes dorsalis, and
possibly this may be a source of infection of the perivascular
lymph channels of the posterior columns of the spinal medulla
in tabes.

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JOURNAL OF MENTAL SCIENCE, APRIL, 1915.

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1 9 1 5 -]

BY F. W. MOTT, M.D.

183

The microscopic examination of brains of cases of paralysis
in which a great abundance of spirochetes was found invariably
exhibited changes indicative of a severe meningo-encephalitis ;
the intensity of the inflammatory process was much more marked
than naked-eye inspection would suggest. Generally speaking,
the perivascular infiltration with lymphocytes and plasma cells,
the capillary endothelial, and the neuroglial proliferation,
together with the venous and capillary stasis, were most marked
in those regions (namely, the frontal and limbic lobes) where
the spirochaetes were most readily and abundantly found. I
have found the spirochaetes in all regions of the brain cortex,
once in the white matter, and once in the grey matter of the
third ventricle.

The Microscopic Changes in the Cortex in Relation to the
Spirochceta'. Colonisation.

My examinations of the brains by sections stained by silver
methods have been attended with unsatisfactory results, except
in the case of an early acute case of general paralysis. Small
portions of the frontal lobe of this brain, which had yielded
very satisfactory results by the emulsion method, were stained
by a modified silver Noguchi method, which, by good fortune,
deposited the silver on the spirochaetes without staining the
neuro-fibrils. Microscopic examination of these sections yielded
some interesting results.

Contrary to the experience of Noguchi, but corresponding
with that of A. Marie, these sections showed the existence of a
feltwork of spirochaetes around an inflamed vessel. Further
examination of sections of this tissue led me to correlate the
perivascular cell reaction with the presence of the spirochaetes ;
for in this section other vessels could be seen congested, in which,
however, there was no perivascular infiltration. Careful micro¬
scopic investigation of the proliferated cells of the sheath of a
vessel showed lying on and between them spirochaetes, and in
the interior of the cells w r ere granules, the products of degene¬
rated spirochaetes (see Fig. 1). Some distance away from the
perivascular focus where the spirochaetes were seen, branches of
this vessel may be observed in which there are proliferated
sheath cells containing granules. Again, little nodules about a
millimetre in diameter may be found consisting of phagocytic

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1 84 TREATMENT OF PARENCHYMATOUS SYPHILIS, [April,

cells, probably reticulo-endothelial cells (histiocytes), filled with
granules—products of degeneration of spirochaetes—some of
which retaining their spiral form, others undergoing granular
degeneration, can be seen lying amidst the cells (see Figs. 2 and
3). It is probable that the cells produce a spirillolytic substance
which causes the granular spirochaetal plasmolysis. This
inflammatory reaction to the spirochaetes tends to congestive
stasis of the vessels of the brain, especially in those regions,
namely, fronto-central, where, owing to the mechanical condi¬
tion of the arterial supply and the venous return, congestive
stasis is favoured in veins and capillaries. Hence these are the
regions where spirochaetes are more readily found, and where
decay and degeneration of the neurones earliest occur. But the
inflammation of the vessels causes, together with the toxins
produced by growth of the spirochaetes, first irritative and then
destructive effects upon the neurones.

The congestive seizures, according to my experience, are
especially associated with microscopic appearances of acute
congestive stasis of the vessels, which may in early cases be
more or less localised. It is probable that the multiplication
of the spirochaetes is associated with the escape into the cerebro¬
spinal fluid of lipolytic and proteolytic toxins, and, therefore,
they can act at a distance from their seat of production, and so
cause, independently of serious active congestive stasis, a pro¬
gressive widespread decay and destruction of the cortical
neurones, such as occurs in the slow dementing forms. The
signs of cortical irritation manifested by convulsive seizures,
and mental excitement manifested by expansive delirium, are
probably indicative of active spirochaetal development, causing
a congestive stasis and liberation of toxins. The spirochaetes
may undergo an active development in one hemisphere, and
cause unilateral convulsions. The irritative process is followed
by decay and destruction of the cortical neurones of one or
both hemispheres, according to the colonisation of the spiro¬
chaetes in one or both hemispheres. This accounts for the fact
that usually one hemisphere is more wasted than the other
when examined post mortem. Especially is this the case when
there have been constant unilateral convulsions ; and I have
known instances where there has been a difference of 60 grm.
in weight between the two hemispheres. And in a few cases
of tabo-paralysis, where the knee-jerks have been absent on

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Fig. 3. —Section of one of these nodules, showing cells filled with the black
granular products of spirochretal plasmolysis. Some spirochaetes are seen in
the middle in process of degeneration. In one part of the section are several
unstained outlines of red blood corpuscles ; this shows that the spirochaites
seen are amidst the perivascular sheath cells, x 1550.

Fig. 4.—Section of a nodule in which the spirocha:tal destruction is more com¬
plete, and within and amidst the cells are the granules of the degenerated
spirochaetes. x 1450.

To illustrate paper by Dr. Mott.

Adlnrd & Son, hufr.

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1 9 1 5 -]

BY F. W. MOTT, M.D.

both sides, I have seen the jerk return on the side of the
motor convulsions. Such cases have shown a great difference
in weight, the hemisphere corresponding to the return of the
knee-jerk being much more wasted. Moreover, I have observed
that, as a rule, when there has been a marked speech affection
the left hemisphere has been the seat of the greater amount of
congestive stasis and destructive decay. These facts tend to
show that it is the colonisation of the spirochaetes, with the
inflammatory reaction produced, which is responsible for the
morbid changes observed post mortem , and that with these
morbid cortical changes may be correlated the signs and
symptoms observed during life. The constant existence of the
Wassermann reaction in the cerebro-spinal fluid may be
regarded as evidence of the presence of spirochaetal toxins ;
and it may be assumed that the granular appearance of the
ependyma of the fourth ventricle, the most characteristic naked
eye appearance met with in this disease, is probably in some
way connected with a prolonged chronic irritation and pro¬
liferation of the ependyma cells, due to the action of the toxin
contained in the fluid of this region.

The Spirochcetcs in Relation to the Cerebro-spinal Irrigation
System of the Brain.

While it is established beyond doubt that tabes and general
paralysis are caused by the spirochaete of syphilis, it is still an
unsettled question why a relatively small proportion of persons
who have been infected suffer with these late manifestations.
I have seen cases of undoubted cerebro-spinal syphilis termi¬
nate in general paralysis and tabes. Strausslerhas also recorded
cases, but these are rare. It is an undoubted fact that examina¬
tion of the cerebro-spinal fluid in the secondary stage shows
that in a considerably greater number of cases a lymphocytosis
exists than clinical symptoms would indicate. This lympho¬
cytosis points to spirochetal infection of the membranes,
although the infection may not cause clinically perceptible
neural irritation or destruction. Ravaut and later Sezary,
Gennerich, Dreyfus, Werther, and other authorities have
emphasised the importance of examination of the cerebro-spinal
fluid both for cells and by the Wassermann and globulin
reactions. The Wassermann reaction may, under treatment,

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186 TREATMENT OF PARENCHYMATOUS SYPHILIS, [April,

disappear from the blood and be present in the fluid. It is
quite possible, therefore, that while treatment may rid the body
of spirochaetes when there has been no infection of the central
nervous system, it is another matter when the organisms have
established colonies in the central nervous system.

In my Oliver-Sharpey lectures I pointed out the fact that
the cerebro-spinal fluid contained no protein nor leucocytes,
and, therefore, invading protozoa, for example trypanosomes or
microbes, owing to the absence of the natural defences of the
blood, found there a safe retreat, and were with great difficulty
eliminated by treatment, because mercury, arsenic, and
antimony, as well as other germicides, do not pass through the
choroid plexus into the cerebro-spinal fluid. There is reason
to believe that the cerebro-spinal fluid functions as the lymph
of the brain. I have shown the existence of a canalicular
irrigation system ( vide Figs. 5 and 6). The very instructive
and valuable researches of the late Professor Goldman have
supported this view. He showed that you could inject 100
c.cm. of a 1 per cent, solution of trypan blue into a vein of an
animal without injuring it, and without staining its central
nervous system. The cells of the choroid plexus alone are
stained. If, however, 2 c.cm. of ao'5 per cetit. solution be
injected by lumbar puncture into the subarachnoid space the
animal often died of convulsions (neuronic irritation). Exa¬
mination of the central nervous system showed the whole spinal
axis and the base of the brain (but not the convexity) stained
blue ; moreover, microscopic investigation showed the spinal
neurones themselves were stained. We shall see that these
facts have a very important bearing upon the treatment of
syphilis of the central nervous system, and the many new
methods which have been introduced to rid the central nervous
system of the syphilitic organisms by direct destruction or by
aiding Nature in doing it. Before, however, passing to a con¬
sideration of recent developments in treatment, it is necessary
to make a few observations upon the methods adopted by
Nature.

The Production oj Specific Antibodies in Relation to

Remissions.

A large experience in the examination of brains of general

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Fig. 5. —Photo-micrograph of the brain of a monkey—experimental anaemia
produced by ligature of two carotid and one vertebral arteries—showing two
vessels with the dilated perivascular sheaths continuous with the subarachnoid
space. Both are distended with a clear fluid ; fine trabecula: (lined by endo¬
thelial cells) can be seen stretching across from the wall of the vessel to the
nervous^substance, therefore the dilatation is not due to an artefact. x 200.

Fig. 6.—Photo-micrograph of the subcortical white matter of the same specimen
as Fig. 5, showing the dilated perivascular spaces distended with a clear fluid.

The contained blood vessels and capillaries are collapsed and empty. In the
grey matter these pericapillary spaces can be seen connected with the peri-
neuronal spaces, but these are not shown in this illustration. x 200.

To illustrate paper by Dr. Mott.

PRINCETON UNIVERSITY

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19*5]

BY F. W. MOTT, M.D.

I8;

paralytics for spirochaetes has led me to think that the inflam¬
matory reaction which is so marked in early cases is the result
of toxins produced by the pullulation of the spirochaetes. The
toxins themselves, and the inflammatory reaction caused by
them, may be a cause of the irritative phenomena, which take
the form of convulsive seizures and psychic irritation, accom¬
panied by mental disorder and delusions. But the inflam¬
matory reaction leads to the production and release of
antibodies which cause destruction of the spirochaetes (Figs. 2
and 3). The symptoms are in all probability, therefore, due
partly to intense local effects, but also to general intoxication,
and reaction of the whole cortex to the poison. As the
natural defences overcome the specific organism (provided the
patient does not die from some intercurrent complication), the
active irritative phenomena tend to subside, and the mind to
recover more or less of its normal functions. But there is, in
almost every case, some degree of neuronic destruction and
dementia following an attack. Even those cases which are
occasionally discharged as cured are, however, only apparently
cured, for sooner or later a relapse occurs, due to the fact that
some of the spirochaetes have resisted the antibodies produced,
and, being immune to them, commence to multiply, producing
toxins which cause a fresh outburst of irritative phenomena,
which upon subsidence leaves the patient the more demented in
proportion to the fresh neural destruction.

This view, based upon facts that I have mentioned, agrees
with the opinion of Ehrlich that each relapse may correspond
with the multiplication of spirochaetes which are resistive to the
antibodies formed, and therefore continue to multiply and
produce toxins until the tissues have elaborated a new and
efficient spirillocide antibody. Such an hypothesis opens up
the question how specific agents such as arseno-benzol com¬
pounds and mercury act as therapeutic agents ; and a number
of experiments have been performed relating to this question,
an admirable summary of which is contained in a recent paper
by Shreiber.

Experiments on Animals in Relation to the Therapeutic Action
of Mercury and Arsenic Compounds.

Ehrlich and Hata believed that salvarsan had a direct

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188 TREATMENT OF PARENCHYMATOUS SYPHILIS, [April,

spirillocide action ; the typical fever following an intravenous
injection is said to be due to destruction of spirochetes. In
support of this statement may be mentioned the fact that
salvarsan exercises a curative influence only on skin lesions
which are specific, presumably by destroying the spirochetes.
Ullmann has found more arsenic in diseased than in healthy
tissue after injection of salvarsan. Loeb and others found
more iodide in syphilitic than in healthy tissues. Doubts have
been expressed whether salvarsan owes its therapeutic proper¬
ties to a direct action on the spirochaetes. There is no doubt
that it may excite a strong leucocytosis, and so favour phago¬
cytic action, and it is certain that an increase of antibodies
and of immunity processes cannot be denied as effects of
salvarsan. Gonders and also Castelli have shown that salvarsan
in vitro does not kill spirilla, but destroys their capability of
developing in the animal body. The experiments of Ehrlich
and Bechold showed that therapeutic agents which are not
active in vitro become active in the body. Ullmann intro¬
duced into the peritoneal cavity of mice nagana trypanosomes
with r5 per cent, solution of neo-salvarsan, and found that
this sufficed to kill the trypanosomes in forty minutes at the
most, a time too short for the production of immune bodies,
etc.

Other experiments seem to show that these benzol compounds
of arsenic have a spirillocidal action ; and this is not due to
the benzol independently of the arsenic, but to a chemiotropic
action by which the arsenic fixes on the parasite. The fact
that (as Gonders showed) trypanosomes may become “ arsenic-
fast ” supports this conclusion. Such trypanosomes probably
do not possess a periplasium which is positively chemiotropic
to this particular arseno-benzol compound, therefore they can
multiply in its presence.

All known mercury preparations can cause a cure of fowl
spirillosis. Experiments of Hahn and Kostenbader showed
that if too large doses of mercury are given a curative effect is
not obtained, whereas smaller doses do effect a cure. Mercury
is not a spirochaete poison in the strict sense of the word ; in
moderate doses it stimulates the production of antibodies ; in
too large doses, by its devitalising effects on the tissues, it
inhibits the production of antibodies. Salvarsan, on the con¬
trary, is more effective in large doses when injected intra-

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PRINCETON UNIVERSITY

BY F. W. MOTT, M.D.

1 9 1 5 •]

189

venously. Intramuscular injections of salvarsan are not so
effective as intravenous injections, which, according to the work
of Meyer, is not the case with mercury.

It is said that the introduction of hydroxyl and amido
groups completely changes the mode of action of these groups
of aromatic compounds of the metals, arsenic, and mercury.
The evidence so far seems to show that we obtain by salvarsan
the death of the spirochastes if the drug has the opportunity
of coming into contact with them, and when followed by the
stimulating effect of mercury, introduced either by inunction or
intramuscular injection, the immunity reactions of the body are
increased, and the cure maintained. These are the two
therapeutic principles underlying the modern treatment of
syphilis, and in the intensive treatment these conditions are
fulfilled. The above account is a summary of a valuable article
by Schreiber.

The Diagnosis.

I will now refer to my experience as regards the Wasser-
mann reactions of the blood and cerebro-spinal fluid in
diagnosis.

The value of the Wassermann reaction in the diagnosis of
general paralysis is shown by the control by post-mortem
examination of a very large number of cases of admissions to
the asylums which have had the blood and fluid examined by
the Wassermann test. A positive reaction of the blood may
occur, and even a marked reaction, in a large number of people
who are not suffering, so far as clinical signs and symptoms
show, with disease resulting from the action of the virus. It
is another matter when the cerebro-spinal fluid gives a positive
reaction, for this is an indication of invasion of the central
nervous system by the spirochaete or its toxin. Whereas post¬
mortem records show before the introduction of the Wasser¬
mann reaction correct diagnosis of general paralysis in only
75 per cent, of the cases, by the aid of the Wassermann reaction
it is rare to find an error of diagnosis in respect to this disease
when, in combination with the history and the clinical signs
and symptoms, the fluid has been examined.

The test employed by my assistants, Dr. Candler and Mr.
Mann, has been conducted on the original Wassermann

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190 TREATMENT OF PARENCHYMATOUS SYPHILIS, [April,

technique—that is, using specially prepared alcoholic extracts
of syphilitic foetal livers, and alcoholic extracts of human heart
with an addition of cholesterol, according to the method of
Sachs. The serum is inactivated by heating to 56° C.

A positive Wassermann reaction in the cerebro-spinal fluid
was only found in cases of general paralysis, tabes, and
syphilitic disease of the central nervous system. The subjoined
table shows the results obtained at the laboratory.

Increase of globulin and pleocytosis do not of themselves
prove the syphilitic character of a disease of the central nervous
system. The strength of the reaction is an important means
of determining whether there is an active spirochaetosis. Thus,
in nearly all cases of general paralysis the reaction is obtainable
in all dilutions.

Results obtained by my Assistants, Dr. Candler and

Mr. Mann.

Positive reactions on cases confirmed as general

paralysis at autopsy . . . . . = 270

Negative reactions on cases shown not to be

general paralysis at autopsy . . . = 52

Negative reactions on cases found to be general

paralysis at autopsy ..... = 5

Total . . . . . = 327

per cent.

Total percentage of accurate results on all cases = 98‘4

Total percentage of positive reactions in cases

of general paralysis . . . . . = 98'I

Asylum Cases: Serum Reaction in General Paralysis.

The Wassermann test on the serum of 300 cases of general
paralysis showed incidence of positive reactions of 98 to 99
per cent. The reaction is generally marked positive, but a
number of cases give slight or moderate reactions. (.Archives
of Neurolog)’, vi, 1914, p. 64. Candler and Mann.)

We may conclude that a positive Wassermann reaction with
the serum is almost a constant feature in general paralysis,
provided that the Wassermann technique is reliable, and
adequate maximum amounts of serum (o’2—0’5) are used.

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1915]

BY F. W. MOTT, M.D.

191

Treatment.

My experience as regards treatment by modern develop¬
ments has not been sufficient to speak at any length, but from
the literature I have read, and from the evidence I have heard
at the Royal Commission, together with my laboratory experi¬
ence, I have come to the conclusion that these late degenerative
forms of syphilis of the nervous system (and I refer especially
to general paralysis) have not been cured, nor even greatly
benefited, by any treatment with salvarsan or neo-salvarsan,
whether administered intravenously or intrathecally. Certainly
in tabes the pains have disappeared, and the patient has
improved, but the same was the case with mercurial inunction.
Some of these cases of general paralysis which have died, and in
which I have examined the brain for spirochaetes, had been
treated by salvarsan prior to admission to the asylum, and in one
case very large doses were employed, and yet I found more
spirochaetes in that case than any other. I have seen cases
during life not only not benefit, but become decidedly worse
after intravenous injection of salvarsan. In a study of the
literature I have failed to find any clear proof of cure or arrest
of general paralysis by any of the methods employed. Those
cases in which a remission of symptoms occurred after treat¬
ment may, as Oppenheim says, be explained by coincidence,
for we know very well cases have remissions without any treat¬
ment. Those in which cure is claimed by enthusiasts may be
due to error in diagnosis. If the salvarsan be introduced into
the blood, and continuously, in the hope that eventually traces
may pass into the cerebro-spinal fluid through the choroid
plexus, and thus the drug be enabled to attack the spirochaetes,
or if it be introduced intrathecally in small doses, as Ravaut
recommends in hypertonic solution, or as others—for example,
Marinesco, Robertson, Swift and Ellis, Purves Stewart—have
done in the form of salvarsanised serum, the question always
arises whether it is able to get at the spirochaetes, and if it does,
whether it is in sufficient amount to kill or harm the organism
without killing or harming the neurone. The similarity in
staining reactions of the neuro-fibrils and the spirochaetes may
be indicative of a similar chemiotropic action.

Candidly, I do not think any measure of success has attended
any of the methods of treatment so far employed for general

LXI. 1 3

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192 TREATMENT OF PARENCHYMATOUS SYPHILIS, [April,

paralysis. In respect to cerebro-spinal syphilis the value of
salvarsan is unquestionable, if it is carefully administered, and a
Herxheimer reaction avoided. Fatal cases have occurred owing
to neglect of this precaution. Salvarsan or neo-salvarsan should
be given in small doses, gradually increasing the amount, and
if there is no urgency it is better even to give a fortnight’s treat¬
ment with mercury before commencing the salvarsan. By treat¬
ment the lymphocytosis will rapidly diminish and disappear even
in parenchymatous syphilitic affections. The Wassermann reac¬
tion and the globulin reaction, however, are extremely obstinate,
and certainly they do not disappear, so far as my experience goes,
after intravenous or spinal intrathecal injections. We must
rather look to the prevention of the spread of syphilis, and its
early diagnosis and treatment by modern methods, as the most
hopeful way of combating this terrible malady. Of the total
admissions to the asylums of the County of London every year
about 1 o per cent, are general paralytics ; more than 1 5 per
cent, of the male admissions are general paralytics, and these
are recruited from men of all social grades, who, prior to the
onset of the disease, for the most part were efficient and pro¬
ductive social units of civic worth and capacity. True, the
females are largely recruited from the unfortunate class of
women, many of whom are mental defectives, but many have
been driven to prostitution by seduction, desertion, and destitu¬
tion, yet a good number are the innocent wives of men by
whom they have been infected, and who are unaware of the
real cause of the disease. Moreover, the histories of the
families of paralytics show that not infrequently they have
transmitted syphilis to their offspring. Incidentally I may
remark of the sixty juvenile paralytics I have-collected, in 20
per cent, one of the parents—usually the father—was a paralytic.
The inquiry I have made regarding the incidence of general
paralysis in the two sexes in the London parishes shows that
the females are relatively more numerous in the poorer East
End parishes, and there is a correlation between female paralysis
and degraded poverty. Now, it is interesting to note that the
higher you rise in the social scale the less often do you meet
with general paralysis in the female sex. This is not the case
with the male sex, for it is pretty equally distributed in all grades
of society. In the juvenile form, where the chances of syphi¬
litic infection are equal, the sexes are equally affected. The

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incidence of general paralysis, therefore, in a population may
be looked upon as a measure of the incidence of syphilis.

(') An address delivered at the opening of the Section of Neurology and
Psychological Medicine, British Medical Association Annual Meeting, Aberdeen,
1914.

Discussion.

Dr. Plaut (Munich) thought that inquiry should be directed to ascertain whether
in general paralysis the spirochsete was present in the parenchyma of other organs
as well as the brain. He believed, however, that the most important results likely
to be obtained at the present stage would be by experiments on animals. He
thought that treatment by the injection of salvarsan intraspinally and into the
ventricles should be continued. He considered that the only effective treatment
would be by the use of salvarsan in the early stages of syphilis.

Dr. J. McIntosh said that some time ago Dr. Fildes and he had advanced the
theory that parasyphilis of the central nervous System was an active syphilitic
process. The failure to find spirochaetes in the lesions was ascribed to their
scarcity and to faulty technique—a difficulty which Noguchi had since overcome.
Further researches had convinced them that late syphilis of the central nervous
system was a tertiary syphilitic process, and was of two types—namely, parenchy¬
matous encephalitis and interstitial encephalitis. The essential difference between
these lay in the tissues affected; in the parenchymatous form the nerve tissue
proper was attacked, while in the interstitial it was the connective tissue and lymph-
vascular structures. An early form of parenchymatous encephalitis occurred in the
secondary period of this disease. The conception was that the structures affected
in the central nervous system were under the influence of allergy—were hyper¬
sensitive to the syphilis toxin. In the encephalitis of the secondary period the
amount of tissue reaction was slight, and yet there was reason to suppose that the
spirochaetes were as numerous as in other secondary conditions. Again, in the
chronic parenchymatous lesions, dementia paralytica and tabes dorsalis, though
the extent of the lesion was great the number of spirochaetes was usually extremely
small. There was thus the same lack of relation between the extent of the lesion
and the amount of the virus as was observed in early and late syphilitic lesions
elsewhere. This was to be attributed to a change in the susceptibility of the tissues.
This hypersusceptibility of the tissues was developed in the later stages of syphilis
as an immunity response to the general invasion of the body during the acute stage.
Recent researches had shown that the central nervous system was affected very fre¬
quently during the acute stage of the disease. In most cases the meninges were alone
involved (though it was not improbable that a few spirochaetes might wander into the
brain substance proper and there lie dormant). The onset of the symptoms of paren¬
chymatous syphilis at a later period was the result of an increased activity of the
spirochaetes which had remained dormant. The spirochaetes, it was believed, entered
the lymphatic system of the brain from the blood, and passed up the afferent nerves
during the secondary period. The researches of Orr and Rows and others had
distinctly shown that the way of the lymphatics was the way of the nerves. Thus
the system lesions of parenchymatous syphilis could be explained (tabes optica,
etc.). The differential diagnosis of many of these cases was extremely difficult,
and any marked and continued improvement, either clinical or serological, in a
supposed case of parasyphilis should at once call for a fuller investigation of the
symptoms on which the diagnosis was based. A quantitative estimation of the
Wassermann reacting power of the serum and cerebro-spinal fluid in all such cases
was of the greatest importance in keeping a record of the case, and in detecting an
early improvement. Treatment was ineffective in parenchymatous syphilis because
antisyphilitic drugs in the blood were unable to pass from the capillaries into the
nerve substances in order to destroy the spirochaetes. Their failure to reach the
brain was not, as some authorities held, due to the drugs not being excreted into
the cerebro-spinal fluid by the choroid plexus; the cerebro-spinal fluid was not the
lymph of the brain. Recent experiments, as yet unpublished, showed that many
chemical substances could pass directly from the blood to the brain substance

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I94 TREATMENT OF PARENCHYMATOUS SYPHILIS, [April,

without the intermediary of the cerebro-spinal fluid. It was, however, true that
substances injected directly into the lumbar sac reach the brain quite readily, since
they had practically only an endothelial membrane to pass through. Recently this
method had been adopted in administering salvarsan and salvarsanised serum in
parenchymatous syphilis. In the cases thus treated and observed with Drs. Head
and Fearnsides at the London Hospital no improvement apart from that due to the
intravenous injection of the drug was noted. The explanation was that, owing to
the great toxicity of the drug on the parenchyma of the brain, a therapeutic dose
could not be administered in this way. Dr. McIntosh said that Dr. Fildes and he
were therefore of opinion that intrathecal injections of salvarsanised serum or of
neo-salvarsan in its present form would be disappointing. A drug capable of
curing parenchymatous syphilis of the brain had yet to be discovered.

Dr. J. E. R. McDonagh thought there could be no doubt that the organisms of
syphilis reached the central nervous system very early in the so-called secondary
stage, and that they invaded the central nervous system in the majority of cases of
syphilis. Since the work of Orr and Rows the opinion had gained ground in this
country that invasion occurred along the lymph channels and spaces of nerves,
but he himself believed that the spore of the Leucocytosoon syphilidis, which was,
in his opinion, the real cause of syphilis, reached the central nervous system either
directly by means of the blood stream, or indirectly by spreading from the
meninges—the meninges having been primarily infected through the blood stream.
He had found the phases of the Lcucocytosoon syphilidis in both thepia mater and
the brain substance in nine of the ten cases of general paralysis so far examined,
and the examination of the cerebro-spinal fluid showed that the neuro-recurrences
are primarily meningeal lesions. Pure arterial lesions were not infrequently seen
early in the disease, giving rise to myelitis if the endarteritis occurred in the cord,
and hemiplegia if it occurred in the brain. The lesion need not necessarily be
localised as in the above, but generalised, and, if occurring in the brain, gave rise
to acute h.-emorrhagic encephalitis, which was a true syphilitic condition. He had
seen a case in which death occurred before any treatment had been prescribed, but its
more frequent occurrence after salvarsan threw light upon the nature of syphilis
of the central nervous system. The organisms traversed the whole brain substance,
but gave rise to no symptoms until the cortex was reached (encephalitis). Later
lesions might appear in any position, and in more than one position, along the
whole course of the vessel from the basilar artery to its finest branch. This
explained how gummata might occur in any part of the brain. Spores could
invade the tissue around the vessels, and give rise to no symptoms until they
completed their life-cycle—months or even years later. Some cases of general
paralysis doubtless arose in this way. Other cases of general paralysis, and
probably most cases of tabes, arose from a direct spread of the organisms from the
meninges into nerve substance. In syphilis of the central nervous system the
pressure of the cerebro-spinal fluid might be raised, there might be a lymphocytosis,
either pure or containing several polymorphonuclear leucocytes and endothelial
cells ; there might be an excess of albumen and globulin, a positive Wassermann
reaction might occur, and oxidase ferments could sometimes be found. Homer,
Swift, and Ellis had obtained good results by injecting intraspinally serum rich in
antibody, but it was feared the treatment was only palliative, and several injections
were necessary to obtain a satisfactory result. The patient was first given an intra¬
venous injection of salvarsan or neo-salvarsan, and an hour later blood was with¬
drawn The following day the serum was collected, mixed with an equal quantity
of distilled water or saline (about 25 c.cm. of each), and after a corresponding
amount of cerebro-spinal fluid had been withdrawn, the diluted serum was injected
into the spinal canal and the patient placed with his head low down, and the bottom
of the bed raised, so as to allow the fluid to gravitate towards the brain. His best
results had been in cases of cerebro-spinal syphilis, in which the improvement had
been remarkable; but, as a rule, about eight injections, given at weekly intervals,
were necessary before the cerebro-spinal fluid approached the normal. In many
cases of cerebro-spinal syphilis as good results might be obtained by intravenous
injections of salvarsan and mercurial inunctions. Some cases of tabes had markedly
improved, the pupil reflexes had returned, the crises had disappeared, and the gait
had become steadier; but much depended upon the stage the patient was in when
treated. Some cases had remained unaltered and a few had been made worse, lie

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knew of five eases in which death resulted, but which would not be published, and
he heard on good authority that many of the cases first treated at the Rockefeller
Institute had recurred, and that the treatment had not proved as satisfactory as
was anticipated. Two cases of general paralysis of the insane which he had
injected were undoubtedly made worse; three other cases improved, but only to a
slight extent. Cerebro-spinal syphilis, tabes, and general paralysis of the insane were
not only extremely closely related, but might merge into one another. If during
the stage of the generalisation of the virus sufficient salvarsan to cure the symptoms
were given, but not to sterilise the system, should a recurrence appear, the chances
were that it would be generalised and indistinguishable from the original trouble.
During the stage of general infection that part of the nervous system which was
fed by blood—namely, the meninges and blood vessels—became infested with
organisms. Sterilisation of the systemic part did not sterilise the meninges.
There were no antibodies except in the cerebro-spinal fluid, with the result that a
generalised meningitis ensued. Should the organisms spread in the nervous part,
but be crippled in the systemic part, as occurred under treatment by mercury,
localised symptoms prevailed, with the appearance of two separate types—the pure
cerebral and the pure spinal. When the extension of the organisms had become
greater and the vascular disturbance more marked, tabes and general paralysis of
the insane would follow, and appear late in the course of the disease when the pro¬
duction of systemic antibodies was checked. If adequate treatment were begun
before the nervous system was attacked, it would presumably always remain free.
If treatment was begun after the nervous system had been attacked, and the treat¬
ment was sufficiently powerful early in the disease to stop the host producing anti¬
bodies, symptoms of the nervous system, should they arise, would be those of
cerebro-spinal meningitis. If the production of antibodies were not stopped till
late in the disease, tabes and general paralysis of the insane would ensue. There¬
fore, if treatment were begun in the secondary stage with mercury alone, or with
one or two injections of salvarsan, the patient would run greater risks of getting
tabes and general paralysis of the insane. If, on the other hand, several injections
of salvarsan were given, and supplemented with mercury, cerebro-spinal syphilis
was more likely to result. The moral was to diagnose a sore at once, and to put
the patient under treatment which might be expected to cure the disease completely.

Dr. Ai.dren Turner, who confined himself to the treatment of parasyphilitic
diseases by intrathecal injections of salvarsanised serum, based his remarks upon
eight cases : six cases of tabes dorsalis, one of primary (tabetic) optic atrophy, and
one of general paralysis. No selection was made. The duration of the symptoms
prior to this treatment varied from three months to five years. Some of the patients
had been treated previously on old established lines. He considered results of
the special treatment from three sides : (1) As to its influence upon the health of
the patient, it might be said that in a general way all the cases showed improvement,
and some increased in weight. The results did not differ from those obtained by
the older methods, or from what might be expected to follow rest in bed, careful
diet, massage, and the general hygiene of a hospital course. (2) As to its influence
upon the special symptoms and signs of the tabetic disorders, in every case the
subjective symptoms were relieved, and in some the pains entirely disappeared.
In a case of advanced tabetic optic atrophy it seemed at first as if vision might
improve, but this did not occur. Contrary to expectations and to the general
experience, the case of early general paralysis showed marked improvement in the
mental symptoms even after the first injection, and this was maintained during the
patient’s stay in hospital. In no one of the cases was there any alteration observed
in the physical signs of the disease. The reaction of the pupils, the state of the
deep reflexes, the sphincters, the deep muscle pain, analgesia, and the impaired
joint sense remained unaltered throughout. The improvement noted in the ataxia
was attributed correctly to the use of Fraenkel's exercises. (3) As to its influence
upon the condition of the cerebro-spinal fluid, at the first examination all the cases
showed a well-marked positive Wassermann reaction. After three injections most
of the cases showed a barely appreciable lessening of this reaction ; in one case a
weak positive reaction was intensified; in no case was a positive reaction rendered
negative. The sole change was a definite reduction in the lymphocyte count
This was observed in every case. It was, he considered, too soon to form a clear
opinion upon the benefits to be derived from this method of treating parasyphilis.

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The impression which the cases had made upon his own mind was that the results
had been no better, nor more quickly obtained, nor more permanent than those which
might result from a thorough course of mercurial treatment. Until a sure and
ready method was available for ascertaining how much arsenic was present in the
infected serum, the procedure had about it a flavour of speculation. The intro¬
duction of arsenic into the cerebro-spinal lymphatic system rendered possible by
this method would be undoubtedly a valuable auxiliary method of combating the
disease in conjunction with mecurial treatment; and Ravaut’s method of direct
injection of neo-salvarsan into the subdural space offered a more ready means of
utilising lymphatic routes in conjunction with mercurial inunction, but Dr. Turner’s
single experience of the method of direct injection was such that he had no desire
to repeat it. The only obvious alteration in the state of the cerebro-spinal fluid was a
decrease in the lymphocyte count, and it was possible that this might be explained by
the dilution of the fluid which a number of injections of 20 c.cm., 30 c.cm. or more of
serum would bring about. As the treatment was free from danger, and as compli¬
cations, such as temporary increase of the lightning pains or the precipitating of
a gastric crisis, were of short duration, further observations would no doubt be
forthcoming, but he thought it too early to say whether it would replace the old-
established methods, or even aid their results.

Dr. Grainger Stewart said that at present he considered it impossible for
anyone to speak with confidence as to the ultimate effects of the newer forms of
treatment in cases of syphilis of the nervous system. It appeared that intraspinal
treatment was sometimes dangerous in cases of general paralysis, and did little or
no good in cases of tabes. His personal experience of intraspinal treatment had
extended over a period of nine to twelve months, during which he had treated over
forty cases. He had first of all given intravenous injections of salvarsan or neo-
salvarsan, and when the reaction of the blood serum had become negative he had
then given from three to six injections of the serum intraspinally. Most of the
cases had been under observation for six months, and it was yet too early to report
on the results of treatment; but in cases of meningeal syphilis or vascular syphilis
the results had been good, and the recovery noted had exceeded in extent and
rapidity that obtained by mercury and iodide. At the same time he would always
advise the combination of the old and the new methods. He had treated four cases of
general paralysis all in the early stages, but had not noted any marked change in
the direction of improvement, but, on the other hand, he had not met with any bad
results. This was, perhaps, due to the fact that he had given very small doses.
He had treated about twenty cases of tabes, and had noted that some improved
and that others remained unchanged, but in no case had he seen a greater degree
of recovery than had been noted in cases treated with mercury and iodide and
Fraenkel's exercises. He had not noted any change in physical signs in tabetic
cases, although this had been more or less common in cases of meningeal syphilis.
The practical point was the distinction between parenchymatous and interstitial
syphilis; in the latter intraspinal treatment undoubtedly did good, while in the
former its value was not yet known, and, despite some of the bad results reported,
he would favour its use provided small repeated doses were given.

Dr. W. Ford Robertson said a remarkable feature of the discussion had been
the unanimity with which the speakers had accepted the view that infection of the
brain by the Spirocheeia pallida was a complete explanation of the causation of
general paralysis. He held that in many respects the evidence was defective.
The disease had never been produced experimentally by infection of lower animals
with the Spirochata pallida. The failure of antisyphilitic treatment suggested that
factors additional to the action of this protozoon were in operation. There was
no proof that all of the spirochaetes described as occurring in the brain were of the
kind alleged ; many of them might be saprophytic forms that had invaded shortly
before death, as bacteria very commonly did. It was strange that it had not been
thought necessary to study control brains in the same way. He believed that the
frequency of the occurrence of the Spiroclutta pallida in the brain of the general
paralytic had been exaggerated, although there remained a large number of positive
observations that were perfectly satisfactory. He had always held that syphilis
was an important factor in the pathogenesis of general paralysis, but he also
maintained that there was a bacterial factor of equal importance. There was a
form of chronic infection, located chiefly in the mucosa of the alimentary tract, by

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bacilli of the diphtheroid group, which was extremely common. It occurred
without complication in a certain type of neurasthenia. It had been demonstrated
that these patients were absorbing diphtheroid bacilli from an infective focus, and
that these organisms, though for the most part destroyed in the blood, were
excreted in large numbers by the kidneys, and could be found, in a disintegrating
or living state, in the centrifuge deposit from the urine. The pathogenic action of
these bacilli was chiefly a neurotoxic one. A similar diphtheroid infection, with
excretion of the organisms in the urine, occurred in cases of dementia praecox, and
there was already weighty evidence that it was an important element in the causa¬
tion of this form of insanity; an hereditary predisposition to the fixation of the
toxins by the cortical nerve cells was apparently another element. A similar form
of chronic infection had been found in several cases of exopthalmic goitre, and in
acute and subacute forms of toxic insanity. In cases of the kind named, autogenous
diphtheroid vaccines had been found to be curative. In general paralysis a similar
chronic infection by diphtheroid bacilli occurred with constancy; the living or
disintegrating bacilli could be demonstrated in the urine. But the general paralytic
was also excreting these bacilli from the blood stream into his cerebral lymphatic
spaces. This was no hypothesis, but a fact that had frequently been demonstrated
in various ways. It was probable that the cerebral vessels, in consequence of a
syphilitic inflammatory process that had affected them, had been rendered permeable
by bacteria circulating in the blood. When other bacteria—such as coliform bacillus
or pneumococci—reached the blood stream, as they were apt to do from infective
foci in the alimentary and respiratory tracts in these cases, they also tended to
pass through the walls of these damaged cerebral vessels. Congestive seizures
were commonly caused in this way. He maintained that the diphtheroid intoxica¬
tion of the brain was an essential part of the pathogenesis of general paralysis In
tabes dorsalis there was always a severe diphtheroid infection of the urethra, until
secondary infections displace it, and consequent intoxication and infection of the
posterior root ganglia and spinal cord by way of the lymphatic channels in the
pelvic nerves, which, in conjunction with a spinal syphilitic lesion, were, he
maintained, a sufficient explanation of the degeneration of the posterior columns
in this malady. He thought it strange that Dr. Mott, while treating this view as
unworthy of notice, should accept the absorption of syphilitic toxins by the same
channels, from a hypothetical syphilitic area somewhere in the neighbourhood, as
a satisfactory explanation of tabes dorsalis. In concluding, Dr. Robertson
maintained that hope of reaching successful methods of treatment of general
paralysis and tabes lay in the recognition of the fact that there was not only a
syphilitic element to combat, but also a bacterial one, and in adopting suitable
measures against both.

Dr. A. W. Falconer said that for the last few weeks he had been giving direct
intrathecal injections by means of the technique described by Schubert of Altona.
This method had the merit of extreme simplicity, the only apparatus required
being an ordinary lumbar puncture needle with a rubber tube and funnel, and a
3 c.cm. glass capsule. So far he had not used a dose larger than o'OOi5 grm. neo-
salvarsan. He had carried out repeated intrathecal neo-salvarsan injections in
twelve of Professor Mackintosh’s cases, but as the results had not differed from
those described by Dr. Turner, it was unnecessary to describe them in detail.

Drs. Campbell Thomson and John Thomson also spoke.

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[April,

WILLIAM BLAKE,

William Blake . By Hubert J. Norman, M.B., Ch.B.,

D.P.H.Edin., Assistant Medical Officer, Camberwell House
S.E.

The association between the artistic temperament and eccen¬
tricity has frequently been noted, and in the lives of Turner,
Vandyck, Michael Angelo, Benvenuto Cellini, Morland, Romney,
Maclise, Landseer, Haydon, Cosway, and many others there is
much to support Nisbet’s contention that “nerve-disorder is a
fundamental element of genius in relation to colour and form.”
To the list already given, the name of William Blake may
fittingly be added, for, just as some of those named at times
passed the boundary which separates sanity from insanity, so
most certainly did Blake also cross the borderland.

It does not, of course, follow that because those attributes
which are usually associated with the term genius are so fre¬
quently found in conjunction with unsound mental action that
they, therefore, arise from the nerve-disorder ; rather is it that
they both proceed from a nervous system in a condition of
unstable equilibrium, which may either exhibit complex reactions
in the production of some work of high intellectual grade, or
tend at other times to display those irregular functionings which
are termed eccentric or insane.

That conduct of an eccentric or even of an insane nature
has been observed in many artists is undoubted ; indeed, so
frequently has such conduct been noted that some writers have
inferred that eccentricity is an invariable concomitant of the
artistic temperament. The tendency to caricature is, however,
very widespread ; that which is a prominent trait in such writers
as Dickens, Swift, Cervantes, or Heine, or of such artists as
Hogarth, Jan Steen, Cruickshank, or Teniers, is no less notice¬
able a feature of all but a few—a very few—people. The usual
conception of a madman as one who rages furiously about,
seeking, like the Devil, those whom he may assault or destroy;
or as, alternatively, one who sits gloomily apart, morose, sullen,
misanthropic, and, like Job, curses the day of his birth ; or
the popular notion of asylums based upon the reading of the
modern homologues of Hard Cash and Valentine Vox as places
where sane people are incarcerated by designing relatives, and

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WILLIAM BLAKE.

From a Painting (1807) by Thomas Phillips, R.A.
Original in the National Portrait Gallery.

To illustrate Dr. Hubert J. Norman's paper.

Go ■gti?'

h by Emery J Talker.

Aiilaid aPSlMjWP

PRINCETON UNIVERSITY'

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where they and the actually insane inmates are almost syste¬
matically maltreated and misused—such examples as these will
suffice to show how easily misconceptions may arise. That
being so, it becomes the more necessary when dogmatic state¬
ments are made to trace them back to their origin, and to see
whether they are based upon facts. Only too often has a vast
superstructure of assertion been built upon an inadequate basis
of reality. Therefore, when we come to the discussion of the
pros and cons regarding the much-vexed question of the mental
stability or instability of William Blake, poet, painter, and
engraver, it is necessary to denude ourselves, as far as is humanly
possible, of any preconception such as that because he was an
artist, and still more because he was also a poet, he must
consequently have been insane. In fact, we must not be led
blindly into the Shakespearean collocation wherein the lover,
the poet—perhaps, had the metre permitted, the artist might
have found himself included also—are ranged cheek by jowl
with the lunatic. On the other hand, it is important not to be
influenced unduly by the dogmatic opinions even of those who,
however distinguished they may be in other branches of litera¬
ture and of learning, are not adequately trained to give a
satisfactory judgment in regard to soundness or unsoundness
of mind. We may accept their statements of fact without
agreeing with their conclusions.

Apart, too, from the question as to whether the term insane
may or may not be fittingly applied to Blake, there is an even
more important issue to be decided. It is the reliability of his
testimony in regard to the veridical nature of his visions and
voices. If his evidence is worthy of credence in this respect,
then it must be allowed that the hallucinations of every insane
person are voices, visions, or messages to other senses, from
some supra-mundane or extra-mundane sphere, unless, of course,
the system of water-tight compartments is to be made use of in
dealing with these matters, as it is in so many other regions
of thought. If, on the other hand, these hallucinations of Blake’s
were really due to some nerve-commotion, and were purely sub¬
jective in their nature, and he yet deemed them to be messages
from without, and his conduct and beliefs were influenced by
them, then—if words are to have any meaning, and are not to
be used as symbols, nor merely for their picturesque effect, nor
simply for the sake of euphony—William Blake was insane

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[April,

WILLIAM BLAKE,

Those who choose to play the game, so beloved of certain
metaphysicians, of “emptying” the term insane of its “contents”
may do so, and solace themselves thereafter with a euphemism
to fill its place. There is little pleasure or credit in logomachy.
Lest, however, any injustice should be done to those whose
views are quoted, their actual words will be given. This method,
while extending perhaps unduly the length of the following
essay, gives to those who read it an opportunity of judging for
themselves whether any unfair inferences have been drawn by
the writer.

The literature in connection with such a subject is, of course,
immense, and the number of commentators, we may almost
say, is legion. An attempt has, however, been made to
embody herein the observations of the more prominent of
those who have discussed the question of Blake’s sanity. A
more ambitious scheme would have necessitated a volume
rather than an essay. It is hoped, however, that sufficient
evidence has been incorporated to elucidate the question at
issue ; further citation and comment, whilst adding to a bulk
which is already rather prodigious, would not increase—except
from a bibliographical point of view—whatever value may
pertain to this study of Blake.

II.

William Blake was born in London in the month of
November, 1757. His father was a hosier by trade ; regarding
him there is, however, little information that is accurate.
By some writers he is said to have been of Irish descent, but
the evidence in regard to this appears to be unsatisfactory
(1). Nor does there seem to be any reason to believe that he
was related to Admiral Robert Blake, although this also is
asserted. It is interesting to note that Blake’s father is
described as being a Swedenborgian, for the influence of
Swedenborg’s writings upon certain of those of William Blake
is obvious. Blake appears to have retained little affection for
his father later in life ; sundry thrashings which that parent
found necessary to administer to his son appear to have
rankled in his memory. “ He long disliked the very word
father. It is often a term of reproach in his poems,” says one
of his biographers (2). It is recorded that some of these

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castigations resulted from his giving descriptions of his
“ visions ”; his parents, not recognising at first the child’s
unusual character, looked upon his statements as the result of
waywardness or of untruthfulness. Even at an early age,
Blake was subject to the outbursts of furious anger which were
noticeable in his later life ; in this connection we read “ Blake’s
fit of fury at being struck was so violent and appalling that it
resulted in the decision that he was not to go to school ” (3).
When he was sixteen years old, and whilst he was working on
a scaffolding in Westminster Abbey, it is recorded that he
threw therefrom a boy who had annoyed him. “ Occasional
outbursts of fury remained always noticeable in Blake,” says
Mr. Ellis. Although it is agreed by most of his biographers
that he was essentially a peaceable man and of mild disposition,
yet they all allow that he was subject at times to excessive
irritability. At these times, the blow followed quickly on the
word, and, on one occasion at least, Blake was involved in
serious trouble as a result. His lack of control was exhibited
in other and milder forms than that of assault, as it will be
pointed out in dealing with his later life.

Of Blake’s mother as little is known as of his father. In
view of Blake’s curious mental history, it is regrettable that so
few details have come to light regarding his heredity, for there
must almost of a certainty have been some morbid strain. Yet
that so little is known is not surprising, for the Blakes were quite
an obscure family, and even at the time of his death William
Blake’s writings and his artistic works were known to compara¬
tively few people. Consequently, little trouble was taken by
anyone to put on record facts concerning his family history.
As there were disagreements with his father, so also Blake
appears to have become estranged from his mother; and, indeed,
he appears to have had no great fondness for the other
members of the family, except in the case of a brother, Robert,
of whom later he spoke and wrote in terms of affection.

Blake’s elder brother James is described as “ having a saving,
somniferous mind,” by one biographer; and from another
writer we gather that although he was “ for the most part an
humble, matter-of-fact man,” yet that he “ had his spiritual and
visionary side too, would at times talk Swedenborg, talk of
seeing Abraham and Moses, and to outsiders seem like his gifted
brother ‘ a bit mad ’—a mild madman instead of a wild and

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stormy” (4). James Blake carried on his father’s business, and
died about three years before his brother William. With him
lived the only sister, of whom little is known ; she is said to
have outlived the rest of the family, and to have died in extreme
penury.

Another brother, John, is stated to have been “a dissolute,
disreputable youth. . . . He lived a few reckless days,

enlisted as a soldier, and died” (5). Blake described him as
“ My brother John, the evil one.” The exact age at which
this brother died is not known, but it is agreed that it was
whilst he was quite a young man.

The youngest brother, Robert, the favourite of William, died
at the age of twenty-four “ of consumption.” Again, there is
little to be recorded concerning this member of the Blake family.
He, too, had artistic tendencies, but his early death did not
allow of anything more than a slight development of these.
Robert Blake died in 1787, and his brother William, with whom
he was then residing, “ watched continuously day and night for
a fortnight by his bedside,” or, at least, so says Gilchrist. The
same biographer describes the effect of this upon the overwrought
watcher: “ At the last solemn moment the visionary eyes
beheld the released spirit ascend heavenwards through the
matter-of-fact ceiling, clapping its hands for joy” (6).

With this generation the family came to an end ; Blake left
no children of his own, nor had he any nephews or nieces. It
may be noted incidentally, and without desiring to lay too much
stress upon this aspect of the family history, that a tendency to
sterility has been noted in degenerating families—as, for instance,
by Morel and Maudsley, and, in regard to those to whom the
character of “ genius ” may be applied, particularly by
Lombroso (7).

Nervous instability showed itself even at an early age in
Blake and by other signs than that of undue irascibility. We
are told that when he was four years old “ he saw God in a
vision put his forehead to the window'” (8); and three or four
years later he returned home one day from Pcckham Rye
asserting that whilst he w r as there he had seen “ a tree filled with
angels, bright angelic wings bespangling every bough like stars,”
while on another occasion he said that he saw' “ the haymakers
at work, and amid them angelic figures walking ” (9). In 1772,
when he was some fifteen years old, and when he, having

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refused to follow his father’s trade, was apprenticed to Basire
the engraver, he had “ a vision of Christ and His apostles”
(10).

Whilst he was still in his teens, Blake began the writing of
poetry ; indeed, according to Gilchrist, “ between the ages of
eleven and twelve, if not before, Blake had begun to write ori¬
ginal irregular verse ”(11). These early poems were published
in 1783 under the title of Poetical Sketches. In 1789 and
in 1794 respectively, there appeared his Songs of Innocence ,
and Songs of Experience: it is by these earlier poems that
Blake’s reputation as a poet has been made, and it is by these
also that he is likely to be judged. Ilis later efforts in versi¬
fication—however much they may appeal to those who revel in
mystical writings—are too rhapsodical, obscure, and, at times,
unintelligible to gain for him many readers. It was, therefore,
before he was thirty-seven years old that his chief poetical work
was done.

In 1782, Blake married, and went to live in Leicester Fields.
The marriage was an important event in his life. His wife,
Catherine, was according to all accounts, a most admirable
woman ; she was patient and long-suffering, and, although her
husband’s wayward and variable disposition must at times have
been a sore trial to her patience, she watched sedulously over
him during the remainder of his life. But for such a worthy
and attentive helpmate, Blake’s career might have ended very
differently ; just as, for instance, the poet Cowper owed so
much to the fostering care of Mrs. Unwin.

Blake continued steadily to work at his engraving and paint¬
ing during the period immediately subsequent to his marriage ;
poetry, too, engaged a good deal of his attention. In 1784
he started his partnership with one called Parker, as a print-
seller and engraver. There is apparently nothing definitely
recorded as to his mental state about this time, but there is
little doubt that he experienced the marked fluctuations which
were characteristic of the whole of his intellectual life. There
has recently been published (12) what Symons describes as “a
light-hearted and incoherent satire,” entitled The Island in the
Moon , which is ascribed to this period. It is an amazing
production, and it may be safely asserted that such a piece of
work is not consistent with sanity on the part of the author.
It is for the most part a mixture of coarse buffoonery, of non-

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scnsical nomenclature, and of scraps of doggerel ; yet here and
there are interspersed some of those delightful lyrics which were
afterwards printed in Songs of Innocence. The association
of these charming poems with the fatuous nonsense and the
utter vulgarity of the remainder of this fantastic performance is
sufficient evidence of the chaotic mental state in which Blake
was at this period. There is a marked lack of cohesion, and
such an irregular sequence of ideas as are characteristic of pro¬
nounced states of excitement ; while the lack of the sense of
proportion which allows of the juxtaposition of refined and
delicate poetic utterances and indecent and ribald expressions
is almost as suggestive of a morbid brain state. It is certain,
therefore, that at the time when Blake wrote this curious medley
he must have been in an abnormal mental condition. Conse¬
quently, we are quite prepared for the suggestion that “ he was
now about to become altogether a myth-maker ”(13). History
makes it sufficiently clear that some such period of unstable
equilibrium usually precedes the onset of the visionary and
prophetic states : witness, for instance, the incident of St. Paul’s
sudden conversion on the road to Damascus, and Swedenborg’s
acute breakdown prior to his persistent delusional condition.
It is interesting to note that about this time Blake was, to a
considerable extent, influenced by Swedenborg. This is obvious
in certain of Blake’s writings, particularly in the Marriage of
Heaven and Hell, which appeared in 1790. The very title
suggests at once Swedenborg’s Vision of Heaven and Hell.
There is, too, in the British Museum, a copy of Sweden¬
borg’s Angelic Wisdom concerning the Divine Love , which was
published in English in 1787, and which contains numerous
marginal notes in Blake’s handwriting. It was likely that
anyone with the mental tendencies which were characteristic of
Blake would be influenced by the mystical theories of the
visionary Swedenborg. With the impatience which was somarked
in Blake throughout his life, and which led him so frequently
to jump to conclusions before he had troubled to arrive at an
adequate comprehension of facts, he soon disagreed with
Swedenborg, and even in the Marriage of Heaven and Hell his
attitude is at times antagonistic. Swedenborg’s theological
writings are, however, clearness itself compared with what
Gilchrist describes as the “ incoherent rhapsodies ” of Blake’s
later years.

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Blake disagreed with Parker in 1787, and the partnership
was dissolved ; he left the house in Broad Street, and went to
live in Poland Street. Whilst there “ he received from a
dream or vision of his dead brother Robert the invention of
the kind of printing in which he published all his autograph
books” (14). In 1789 appeared the Book of Thel, one of the
earliest of the “ prophetic ” books, and in the following year
the Marriage of Heaven and Hell was published. It is, as
Gilchrist says, “ still more mystical ” than its predecessor, and
it is apparently a record of visions and hallucinations. Here
again are noticeable the irrelevance and disconnectedness
which characterised so markedly The Island in the Moon.
Blake informs us that the “ Prophets Isaiah and Ezekiel dined
with him and that he questioned them, asking them 4 how they
dared so roundly to assert that God spake to them ’ ” ; and he
mentions also a visit which he made to a “ printing-house in
hell,” wherein were dragons, a viper, lions, etc.—unusual sights
in most well-regulated printing establishments. The presses
were presided over, we may presume, by printer’s devils ! For
anyone with the markedly exegetical disposition of the
numerous interpreters of the mythology of Blake, and endowed
also with a sense of humour, there would be found much
material for a satirical exposition of the hidden meaning of this
curious work.

The Marriage of Heaven and Hell is terminated by a note,
which runs as follows : 44 This angel, who is now become a
devil, is my particular friend. We often read the Bible
together in its infernal or diabolical sense, which the world
shall have if they behave well. I have also the Bible of hell,
which the world shall have whether they will or no.”

One law for the Lion and the Ox is Oppression. It is this
book which Swinburne designates as exhibiting 44 the high-
water mark of his (Blake’s) intellect.” In his turgid phraseology
— 44 Every sentence bristles with some paradox, every page
seethes with the blind foam and surf of stormy doctrine ; the
humour is of that fierce, grave sort, whose cool insanity of
manner is more horrible and more obscure to the Philistine
than any sharp edge of burlesque or glitter of irony ; it is huge,
swift, inexplicable, hardly laughable through its enormity of
laughter, hardly significant through its condensation of
meaning.” It may be said that Swinburne’s essay is more

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valuable as a revelation of Swinburne than as a criticism of
Blake. Had Blake lived to read it he might well have prayed
to be defended from his friends !

Other books of a similar character were written by Blake
about this time ; more “ dreamy books of prophecy,” to use
Gilchrist’s phrase. One, entitled The French Revolution , was
inspired by the dramatic events which were taking place in
France, for Blake was an ardent republican, and walked the
streets adorned with the bonnet-rouge. Another, which he
called the Visions of the Daughters of Albion, appeared in 1793.
In this book a number of shadowy characters with ill-sounding
names, such as Theotormon, Bromion, Oothoon, and Urizen,
conduct themselves in such a mysterious manner as to be still
a puzzle to the industrious commentators.

In 1793, Blake left Poland Street, where he had resided for
five years, and went to live in Lambeth at Hercules Buildings.
In 1794 appeared his Songs of Experience , in which he returned
to the poetical style of the Songs of Innocence. A comparison
of this book with the dreamy, mystical, often incoherent
writings which preceded it, and with similar ones which
succeeded it, gives rise to a feeling of keen regret that his
mental state did not permit him to continue along the lines of
lyrical versification. As a lyric poet, and especially where
simplicity and directness are in question, he has seldom been
equalled. There is, however, a curious trait in Blake’s character
as a poet, and one that is noticeable even in the Songs of
Experience ; it is the manner in which he would allow the most
obvious doggerel and imperfect scansion to remain in his poetry,
either because he did not notice it, or because he composed
and wrote too hastily and would not trouble to revise. Mr.
Ellis says that he did not correct his poems because he could
not; the mood of conception had not its needful prolongation
into a mood of judgment. “ This deficiency in Blake, this
critical blindness, was almost always absolute and unconscious
like colour-blindness or tone-deafness to others.” The same
writer goes on to say that this “ misfortune cost him friend after
friend” (17); Blake resented the criticism from others which
he was unable to supply himself, and he consequently broke
off friendly relationships with those who dared to criticise his
productions. It is difficult to conceive how anyone could leave
such a verse as the following one unaltered unless he suffered

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from mental defect in the direction of critical ability. It occurs
in the Songs of Experience.

“When the voices of children are heard on the green,

And whisperings are in the dale,

The days of my youth rise fresh in my mind,

My face turns green and pale.”

Other passages might be quoted illustrative of the same
defect, but this one will suffice to show how Blake, even in what
Gilchrist describes as the “ more lucid writing ” of the Songs
of Experience , could fail to realise poetical faults, and could
allow such a bathetic line as that of the “ green and pale ” face
to remain.

As it was with his poetry, so it was with his drawings and
painting. Though he was capable in these directions also of
remarkable and strikingly beautiful results, yet here, too, his
work suffered from his lack of artistic training, and also from
his tendency to exaggeration. Only too frequently the beings
whom he depicted are disproportioned, and some of his figures,
if they are judged dispassionately, and not with the enthusiastic
fervour of devotees who consider everything he did worthy of
admiration, and all things that he wrote credible, appear as
if they were the handiwork of a tyro in the art of drawing.
His colouring, though often delicate and obviously the work of
an exceptionally talented artist, was at times crude, amateurish,
and evidently done in haste. Ellis describes him as “ an in¬
harmonious colourist, spotty, feeble, and incoherent.” Another
critic remarks : “ It must be confessed that Blake’s work suffers
from the obsession of certain ill-formed types of humanity, with
the cone-shaped heads, the strongly lined brows, the bull necks,
the exaggerated and often incorrect undulation of muscle . . .
His was a genius where human expression was lamed by an
unnatural vividness of spiritual vision, and a ray of real truth is
continually followed by the mutterings of the incomprehensible ”

(i;a).

Blake was not at this time in a mood to depreciate his own
wares. In 1794, he issued a leaflet in which the following
passage occurs : “ Mr. Blake’s power of invention very early
engaged the attention of many persons of eminence and fortune,
by whose means he has been regularly enabled to bring before
the public works (he is not afraid to say) of equal magnitude

LXI. 14

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WILLIAM HLAKE,

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and consequence with the productions of any age or country ”
(18). Such statements certainly point to a condition of mental
exaltation, and Nordau would assuredly designate it by his
favourite expression, megalomania. This is not a solitary
instance of Blake’s self-appreciation ; other examples will be
given later of a similar character.

In 1794, still more prophetical writings were published with
the titles, Europe and Urizeti. The latter is described by
Gilchrist, who was an ardent opponent of those who maintained
the mental unsoundness of Blake, as “shapeless, unfathomable,”
and of the Song of Los, which appeared in 1795, he remarks
that “in it we seem to catch a thread of connected meaning.”
There are enthusiasts, however, who do not agree with Gilchrist,
and who find meanings and an understandable mythus in the
prophetic books ; but many, in Blake’s own words, “ avoid the
petrific, abominable chaos” (19). In Urizen , and indeed in
other prophetical books, one gets the feeling of being involved
in a horrid nightmare, as if one were in the grip of an incubus
—“in a horrible, dreamful slumber,” as Blake so aptly expresses
it. As there are probably few who venture so far in their
reading of Blake as the prophetic books, some excerpts from
this particular one may be of interest:

“ From the caverns of his jointed Spine
Down sunk with fright a red
Round globe, hot, burning deep,

Deep down in the Abyss;

Panting, Conglobing, Trembling,

Shooting out ten thousand branches
Around his solid bones.

• «•••■

In ghastly torment sick,

Within his ribs bloated round,

A craving, Hungry Cavern.”

The lines which follow seem like a prophecy of the “Futurist”
school of painting:

“And his world teem’d vast enormities,

Fright’ning, faithless, fawning,

Portions of life, similitudes
Of a foot, or a hand, or a head,

Or a heart, or an eye, they swam mischievous,

Dead terrors, delighting in blood” (20).

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The term “ vast enormities ” is, however, not inapplicable to
some of Blake’s own efforts. In the Book of Ahania, which was
published in 1795, there are equally horrific passages ;

“The clouds of disease hover’d wide
Around the Immortal in torment,

Perching around the hurtling bones,

Disease on disease, shape on shape,

Winged, screaming in blood and torment.

The shapes, screaming, flutter’d vain.

Some combin’d into muscles and glands,

Some organs for craving and lust;

Most remained in the tormented void ;

Urizen’s army of horrors ” (21).

Blake has mustered a not inconsiderable “ army of horrors ”
himself, and anyone may be forgiven for hoping that his rest
may not be broken by the onrush of the poet’s ephialtic
squadrons.

It was during the period of Blake’s residence at Hercules
Buildings that the curious episode relating to the poet’s realistic
interpretation of his readings in Milton occurred. Gilchrist gives
the story on the authority of Mr. Butts, who bought largely of
Blake’s artistic productions, and who knew him intimately.

‘ At the end of the little garden in Hercules Buildings there
was a summer-house. Mr. Butts, calling one day, found Mr.
and Mrs. Blake sitting in this summer-house freed from ‘ these
troublesome disguises ’ which have prevailed since the Fall.

' Come in!' cried Blake, ‘ it's only Adam and Eve,you know ! '
Husband and wife had been reciting passages from Paradise
Lost in character, and the garden of Hercules Buildings had to
represent the Garden of Eden, a little to the scandal of wonder¬
ing neighbours on more than one occasion.” Gilchrist admits
that if others “ were on a sudden to wander in so bizarre a
fashion from the prescriptive proprieties of life, it would be
time for our friends to call in a doctor, or apply for a com¬
mission de lunatico ”; but he excuses such vagaries in Blake
because he “ lived in a world of ideas ; ideas to him were more
real than the actual external world ” (22). It is a dangerous
excuse, and one which might be made on behalf of many of
the insane. They, too, dwell in a world of ideas ; in the usual

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terminology the subjective aspect of their mental life is pre¬
dominant. The person with hallucinations will, more often than
not, refuse to believe the statements made to him by others
when they contradict the evidence of his “ voices ” or of his
“ visions,” or when they are in opposition to the monitions of
his Socratic “ Demon ” or “ Genius.” Thus we find Blake
writing in 1799: “I find more and more that my style of
designing is a species by itself, and in this which I send you
have been compelled by my Genius or Angel to follow where
he led ”(23).

His dead brother, Robert, who, according to Blake, revealed
to him the method of etching which he employed in the
illuminated books, acted to some extent as his invisible monitor.
In this same year, he wrote to Hayley : “I know our deceased
friends are more really with us than when they were apparent
to our mortal part. Thirteen years ago I lost a brother, and
with his spirit I converse daily and hourly in the spirit, and
see him in my remembrance, in the regions of my imagination.
I hear his advice, and even now write from his dictate ” (24).

During the summer of 1800, Blake experienced a period of
depression. There is evidence of this in a letter which he wrote
in July of that year : 11 1 begin to emerge from a deep pit of
melancholy—melancholy without any real reason—a disease
which God keep you from” (25). By the time that September
arrived, he was again cheerful ; in a letter to Flaxman, the
sculptor, he speaks of his “ present happiness,” and says that
“ the time has arrived when men shall again converse in Heaven
and walk with angels.” There are references in the same letter
to the troubled mental phase through which he had recently
passed :

“ Paracelsus and Behmen appeared to me, terrors appeared in the
Heavens above,

And in Hell beneath, and a mighty and awful change threatened the
Earth.

The American War began. All its dark horrors passed before my face
Across the Atlantic to France. Then the French Revolution com¬
menced in thick clouds,

And my Angels have told me that seeing such visions I could not
subsist on the Earth,

But by my conjunction with Flaxman, who knows to forgive nervous
fear ” (26).

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Later, in the month of September, 1800, Blake and his wife
left Hercules Buildings and went to reside at Felpham in
Sussex. This change of residence is said to have been brought
about at the suggestion of William Hayley, author of The
Triumphs of Temper, biographer of Romney and of Milton, and
essayist, who was living close to Felpham at this time. Hayley
was engaged in writing a biography of his friend the poet
Cowper, who died in April, 1800; and he was desirous that
Blake should engrave the plates for the illustration of his work.
During the early part of Blake’s stay at Felpham the relations
between the two men were of the most friendly character.
Hayley was a kindly-natured man, and, in addition to being an
author himself, was apparently anxious to play in a small way
the part of Mecaenas. He has been systematically abused by
several of those who have written about Blake in an obviously
partisan manner, because a quarrel took place between the two,
or rather because, according to Blake’s statements, he resented
certain of Hayley’s criticisms. Swinburne, in his misguided
essay on Blake, is the worst offender in this respect. All these
writers, although they were aware of Blake’s irritability and of,
at times, his morbid suspiciousness in regard to certain people,
have apparently chosen to overlook these traits in his character.
Here again was a marked inconsistency in Blake’s character :
although keenly desirous of the friendship of others, he quar¬
relled with many of his friends( 1 ), and, apparently, for no ade¬
quate reason. At least his biographers for the most part do
not seem to be able to give the reason, but, in default of that,
they seize upon anything that might seem to justify Blake in
his estrangements, even if by so doing they have to deal hardly
with those with whom he quarrelled. They would have been
more just to Blake and to his friends if they had been pre¬
pared to admit that these troubles arose for the most part from
the inherent mental instability from which Blake suffered.

Blake wrote to Flaxman soon after his arrival in Felpham,
and from that letter it may be judged that he was pleased
with his new surroundings, and also that his “ visions ” and his
“ voices ” had not by any means departed from him. “ Felpham
is a sweet place for study, because it is more spiritual than
London. Heaven opens here on all sides her golden gates ;
her windows are not obstructed by vapours ; voices of celestial
inhabitants are most distinctly heard, and their forms more

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distinctly seen ; and my cottage is also a shadow of their
houses.” In the same letter there is a passage which clearly
shows the exalted state which characterised him at this time :
“ I am more famed in Heaven for my works than I could well
conceive. In my brain are studies and chambers filled with
books and pictures of old, which I wrote and painted in ages of
eternity before my mortal life ; and those works are the delight
and study of archangels” (27). Later in the year, the same
elated mood is apparent in his letters : “ Time flies very fast
and very merrily. I sometimes try to be miserable that I may
do more work, but find it is a foolish experiment ” ; and in
May of the following year (1801) lie wrote: “ Mr. Hayley
acts like a prince. I am at complete ease.” In September,
1801, there is an interesting passage in one of his letters which
gives much insight into his mental state : “ I labour incessantly.

I accomplish not one half of what I intend, because my abstract
folly hurries me often away while I am at work, carrying me
over mountains and valleys, which are not real, into a land of
abstraction where spectres of the dead wander. This I endeavour
to prevent ; I, with all my whole might, chain my feet to the
world of duty and reality. But in vain ! the faster I bind, the
better is the ballast ; for I, so far from being bound down, take
the world with me in my flights, and often it seems lighter than
a ball of wool rolled by the wind. . . . But as none on

earth can give mental distress, and I know all distress inflicted
by Heaven is a mercy, a fig for all corporeal. Alas ! wretched,
happy, ineffectual labourer of Time’s moments that I am ! Who
shall deliver me from this spirit of abstraction and improvi¬
dence ? ” (28) In a previous letter, he had written of his
visions by the sea-shore of “ Heavenly men beaming bright,”
who appeared as “ One man,” and spoke to him. But
when January, 1802, arrived, his mood was one of despondency ;
and the close application to work, which Hayley apparently
suggested, did not suit Blake’s increasingly restive state. He
regarded the suggestion suspiciously because of the commands
which his spiritual monitors had issued to him, which were that
he should busy himself in other ways than those which the
practical Hayley recommended. “When I came down here,”
he wrote, “ I was more sanguine than I am at present.” He
thought that Hayley would, however, be able to lift him out of
difficulty, although this would be no easy matter in the case of

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one such as himself, who, “ having spiritual enemies of such
formidable magnitude, cannot expect to want natural hidden
ones.” He objected to routine work ; he looked upon it as his
duty “ to lay up treasures in Heaven ” in fulfilling the behests
of the voices. Their commands were issued frequently : “ I am
under the direction of messengers from Heaven, daily and
nightly.” How true the sentence is which follows : “ But the
nature of such things is not, as some suppose, without trouble
or care.” Those whose work brings them in daily associa¬
tion with men and women who are influenced by “ voices ”—
auditory hallucinations—can certainly testify to the truth of
such a statement. It is remarkable, too, how seldom the
“ voices ” direct these persons to the performance of reasonable
actions. In Blake’s case, it is difficult to see why he should
not have been instructed to direct some of his energies towards
earning the means of subsistence for his wife and for himself.
It does not seem unreasonable to suggest that in this way also
he might have laid up treasure in Heaven !

Towards the end of the year 1802, Blake was able to write
more cheerfully; the dark mood had passed, and he was again
experiencing exaltation. “ I have been very unhappy, I am so
no longer. I am again emerged into the light of day. ... I
have travelled through perils and darkness not unlike a champion.

I have conquered, and shall go on conquering. Nothing can
withstand the fury of my course among the stars of God and in
the abysses of the accuser ” (29). But he evidently was still
desirous of returning to London. In a letter written in April,
1803, he asked Mr. Butts to congratulate him in the prospect
of an early return thereto : “Now I may say to you . . . that
I can alone carry on my visionary studies in London unannoyed,
and that I may converse with my friends in eternity, see visions,
dream dreams, and prophesy and speak parables unobserved.”
In the same letter, he speaks of a work upon which he has been
engaged, a poem entitled Milton. In his characteristic manner
he thus describes how it was conceived : “ None can know the
spiritual acts of my three years’ slumber on the banks of ocean,
unless he has seen them in the spirit, or unless he should read
my long poem descriptive of those acts ; for I have in these
years composed an immense number of verses on one grand
theme, similar to Homer’s Iliad or Milton’s Paradise Lost\ the
persons and machinery entirely new to the inhabitants of the

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earth (some of the persons excepted). I have written this poem
from immediate dictation, twelve or sometimes twenty or thirty
lines at a time, without premeditation, and even against my will.
The time it has taken in writing was thus rendered non-existent,
and an immense poem exists, which seems to be the labour of a
long life, all produced without labour or study. I mention this
to show you what I think the grand reason of my being brought
down here.” Another poem, or another portion of the same
immense poem, was published later with the title of Jerusalem.
Blake describes it as a “ sublime allegory,” and considers it
as “the grandest poem that this world contains.” If one accepts
his definition of the most sublime poetry as “ allegory addressed
to the intellectual powers, while it is altogether hidden from the
corporeal understanding,” it may be granted that he was justified
in his claim to a superlative degree of merit. He did not,
however, take any praise to himself for these writings : “ The
authors are in eternity,” and he was only “the secretary” who
wrote at their dictation. Even the perfervid Swinburne boggled
at these poems : “ Human readers, if such indeed exist beyond
the singular or the dual number, will wish that the authors had
put themselves through a previous course of surgical or any
other training which might have cured a certain superhuman
impediment of speech, very perplexing to the mundane ear ; a
habit of huge, breathless stuttering, as it were a Titanic stammer,
intolerable to organs of flesh” (30). The evolutions of the
characters in Miltoti are certainly perplexing, but what is one
to expect from, for instance, the dwellers in a town named
Golgonooza, or what else than dyspepsia could arise from
“Bowlahoola,” which is “the stomach in every individual man.”
Imagine Enitharmon with a pain in his Bowlahoola! It is
difficult to refrain from levity when one considers the wild
welter of verbiage in such a poem as this ; it is so reminiscent
of “ Jabberwocky” that it stimulates the risible faculties—if one
may be allowed the phrase. Consider the following invocation:

“Arise, O Sons, give all your strength against Eternal Death,

Lest we are vegetated, for Catliedron’s Looms weave only Death,

A Web of Death, and were it not for Bowlahoola and Allamanda,

No Human Form, but only a Fibrous Vegetation,

A Polypus of soft affections without Thought or Vision

Must tremble in the Heavens and Earths thro’ all the Ulro space,

Throw all the Vegetated Mortals into Bowlahoola.”

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The carnivorous mortals would perhaps prefer to read vege¬
tarian for vegetated in the last line !

In another place we read of a motley gathering, chiefly of
insects, which dances round “ the Wine-presses of Luvah ” :

“The Earwig arm’d ; the tender Maggot, emblem of immortality;

The Flea, Louse, Bug, the Tape-worm, all the Armies of Disease;

Visible or invisible to the slothful, vegetating man ;

The slow Slug; the Grasshopper, that sings and laughs and drinks.

Winter comes : he folds his slender bones without a murmur” (32).

The Earth-worm is there also in company with the Nettle and
the "indignant Thistle.” It all sounds more like the vision
of someone who had been dancing too near to the wine-presses.

In this poem, Milton , there occurs a passage which
evidently refers to a seizure or fit during his stay at Felpham,
or, as Ellis describes it, he was overwrought by visionary
fancy.

“ My bones trembled, I fell outstretch’d upon the path

A moment, and my Soul return’d into its mortal state,

So Resurrection and Judgment in the Vegetable Body,

And my sweet Shadow of Delight stood trembling by my side.”(33)

It was probably also while he was at Felpham, according to
Ellis, that, in a vision, Cowper came to Blake and said : “ O
that I were insane always! I will never rest till I am so.
You retain health, and yet are as mad as any of us all—mad
as a refuge from Bacon, Newton, and Locke.”

In the summer of 1803, Blake was unfortunately involved
in a troublesome affair which led to his being tried for sedition.
A drunken soldier blundered into Blake’s garden and, when
requested to leave, became offensive and impertinent. Where¬
upon Blake incontinently took him by the elbows, marched
him out, and “ pushed him forward down the road about fifty
yards.” This drunken blusterer, in a spirit of revenge, preferred
a charge against Blake of having used seditious language
during the encounter, wherein he was supported by a “ perjured
comrade.” The trial, needless to say, resulted in a verdict in
Blake’s favour, but this incident naturally tended to prejudice
him still further against the district. With his tendency to
ascribe his mischances to some persecutionary scheme, Blake
looked upon this affair as being of the nature of a subtle plot;

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he “ used to declare the Government, or some high person,
sent the soldier to entrap him.” In company with Gilchrist
we may “ take the liberty of regarding this as a purely visionary
notion ”(35).

From what has been stated it will be obvious that Blake’s
mental condition during the period of his stay at Felpham
was one of marked instability. Even those who resent the
ascription to him of the term “ insane ” admit this. “ By the
sounding shore,” says Gilchrist, “ visionary conversations were
held with many a majestic shadow from the past—Moses and
the Prophets, Homer, Dante, Milton.” Swinburne says “ that
too much of Blake’s written work while at Felpham is wanting
in executive quality, and even in decent coherence of verbal
dress, is undeniable ” ; and adds that “ everything now written
in the fitful impatient intervals of the day’s work bears the
stamp of an over-heated brain, and of nerves too intensely
strung.” Swinburne has, however, his own method of account¬
ing for this. It was due to the “ sudden country life, the taste
and savour of the sea,” which “ touch sharply and irritate
deliciously the more susceptible and intricate organs of mind
and nature. How far such passive capacity of excitement
differs from insanity ; how in effect a temperament so sensuous,
so receptive, and so passionate, is further off from any risk of
turning unsound than hardier natures carrying heavier weight
and tougher in the nerves, need scarcely be indicated ” (36).
What does scarcely need to be indicated, after reading such
passages as these, is that Swinburne was little competent to
give a reasoned opinion on the matter of Blake’s mental
unsoundness. Only prejudice could have allowed him to draw
such a conclusion from the evidence which he himself gives.
The last part of the passage quoted is perilously like
nonsense.

Flaxman, who also resented any imputation of insanity to
Blake, states, in a letter to Hayley in 1804, that “ Blake’s
irritability, as well as the association and arrangement of his
ideas, do not seem likely to be soothed or more advantageously
disposed by any power inferior to That by which man is
originally endowed with his faculties ” (37). Mr. Ellis speaks
of the “ deplorable and hasty state of the drawings towards the
close of Milton ” ; and he adds that “ they betray worn-out
patience, jarred nerves, and a distracted mind ”(38). Gilchrist,

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another ardent advocate of Blake’s sanity, comments as follows
on Jerusalem : “Dark oracles, words empty of meaning to all but
him who uttered them,” and again he describes it as “ Such a
chaos of words, names, and images, that, as the eye wanders,
hopeless and dispirited, up and down the large, closely written
pages, the mind cannot but busy itself with the question, how
a man of Blake’s high gifts ever came to produce such ; nay,
to consider this, as he really did, his greatest work.” In
regard to the Milton his comment is : “ As this work has no
perceptible affinity with its title, so the designs it contains
seem unconnected with the text ”(39). In such a way will
prejudice—or ignorance of the inferences as to disordered
brain function which may be drawn from certain symptoms—
blind critics, and prevent them from giving a verdict in accord¬
ance with the evidence.

Blake returned to London in the autumn of 1803 ; he took
lodgings in South Molton Street, and there he continued to
reside until 1821. The exaltation and fervour seemed for a
short time to have abated. Then in October, 1 804, he writes to
Ilayley a letter in which the following passages occur: “ For
now ! O Glory! and O Delight! I have entirely reduced that
spectrous fiend to his station, whose annoyance has been the ruin
of my labours for the last passed twenty years of my life. He is
the enemy of conjugal love, and is the Jupiter of the Greeks, an
iron-hearted tyrant, the ruiner of ancient Greece. I speak with
perfect confidence and certainty of the fact which has passed
upon me. Nebuchadnezzar had seven times passed over him ;
I have had twenty. Thank God I was not altogether a beast as he
was, but I was a slave bound in a mill among beasts and devils.
These beasts and these devils are now, together with myself,
become children of light and liberty, and my feet and my wife’s
feet are free from fetters. O lovely Felpham, parent of immortal
friendship, to thee I am eternally indebted for my three years’
rest from perturbation and the strength I now enjoy.
Suddenly ... I was again enlightened with the light I
enjoyed in my youth, and which has for exactly twenty years
been closed from me as by a door and by window shutters.” He
goes on to speak of having received “spiritual aid” from Romney,
and continues : “ He is become my servant who domineered
over me, he is even as a brother who was my enemy. Dear
Sir, excuse my enthusiasm or rather madness, for I am really

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drunk with intellectual vision whenever I take a pencil or graver
into my hand ... I am now satisfied and proud of my
work ” (40).

In December, 1805, Blake writes to Hayley much in the
same strain : “ You, dear Sir, are one w ho has my particular
gratitude, having conducted me through three that would have
been the darkest years that ever mortal suffered, which were
rendered through your means a mild and pleasant slumber. I
speak of spiritual things, not of natural, of things known only
to myself and to spirits good and evil, but not known to men
on earth. It is the passage through these three years that has
brought me into my present state, and I know that if I had not
been with you I must have perished” (41). Yet within a very
short time and for no adequate reason Blake broke with Hayley;
the feeling of acute suspiciousness in regard to the motives of
others recurred. And in the same way he came to regard
Flaxman as one who was working against him. “ Blake, with
a burst of fury, decided,” says Mr. Ellis, “ that they were not
friends at all, since they had been, while pretending to patronise
him, quietly conspiring to reduce his prices ” (42). Why they
should have so conspired it is difficult to understand, and,
indeed, there does not seem to be any reason to believe that there
was any adequate basis for such an idea other than in Blake’s
morbid imaginings. In much the same way Blake’s friendship
with Stothard came to an end in 1808. Blake had made a
drawing of Chaucer’s Canterbury Pilgrims , and this drawing
was apparently left about in his room at South Molton Street.
There it was seen by a visitor who was acquainted with Stothard;
this visitor, whose name was Cromek, had been an engraver, a
pupil of Bartolozzi, but had given up engraving to become a
publisher. It was Cromek who had bought from Blake the
designs to Blair’s Grave. There was apparently an under¬
standing—on Blake’s part, at any rate—that in addition to
designing these drawings, the artist should also engrave them.
Cromek, however, gave this part of the work to Schiavonetti—
an exceedingly able engraver—and Blake was furiously angry
with him for so doing. He wrote him an “insulting letter,’
and demanded more money; “ Blake,” says Mr. Ellis, “ when
not affectionately polite, was ferociously offensive.” Another
inconsistency showed itself in Blake during this incident ;
although he posed as a money hater, he began to “ wrangle

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abusively for more pay ” (43). Accordingly he quarrelled with
Cromek, and much abuse has been levelled at Cromek by
Gilchrist, Swinburne, and others. Cromek, then, having seen
Blake’s sketch of the Canterbury Pilgrims , called upon Stothard
and may have spoken to him about it, or it is possible that
Blake may have mentioned it to Stothard himself. However
it may have been, we know that Stothard painted the well-
known picture with the same title which is now in the National
Gallery. According to Mr. Ellis, Blake had called on Stothard
whilst the latter was engaged in painting this picture, “ saw him
at work,” and politely praised “ anything that he could praise
in the work.” Yet when Stothard’s picture did actually appear
Blake again felt that he had been betrayed and injured ; he
became incensed with Stothard, and this friendship, too, came
to an end. He even developed persecutionary ideas in regard
to Stothard. Blake had hung his original design of the Can¬
terbury Pilgrims over a door in his sitting-room, “where, for a
year perhaps, it remained.” When, on the appearance of
Stothard’s picture, he went to take down his drawing, he found
it nearly effaced, “ the result of some malignant spell of
Stothard’s, he would, in telling the story, assure his friends.”
Whereupon Flaxman is stated to have expostulated with him,
pointing out that if a pencil drawing were left exposed so long
to air and dust, he could hardly expect any other result.

Gilchrist states that the quarrel with Cromek and with Stothard
left Blake “ more tetchy than ever ; more disposed to wilful
exaggeration of individualities already too prominent, more prone
to unmeasured violence of expression,” and he goes on to say
that “ the extremes he again gave way to in his design and
writings—mere ravings to such as had no key to them—did him
no good with that part of the public the illustrated Blair had
introduced him to.” Then, evidently feeling that such statements
might give rise to a suspicion that all was not well with Blake’s
mental state, he goes on to say that, though there was “ now
established for him the damaging reputation, ‘mad,’ by which the
world has since agreed to recognise William Blake,” he maintains
that he was certainly not so, preferring apparently that Blake
should be held responsible for his waywardness, irritability, and
quarrelsomeness.

There is, however, other evidence of Blake’s disordered mental
state about this time. There is, for instance, a quotation from

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a note-book of Blake’s which is suggestive. It apparently refers
to Stothard, who, we are told, had a long nose. It is as follows:
“ I always thought Christ was a snubby, or I should not have
worshipped him, if I had thought he had been one of those long
spindle-nosed rascals.” With his irritability there was again a
progressive exaltation, and it is interesting to note that prior to
this there had been a period of profound dejection. In his
note-book, under the date “Tuesday, Jan. 7, 1807,” there is an
entry—“ Between two and seven in the evening : Despair,” and
Mr. Ellis states that “ Blake had lately been reduced to one
of his fits of deep melancholy at this time” (45). Now the
feeling of elation had returned to him again. In 1809, he held
an exhibition of some of his pictures, and in the “ descriptive
catalogue ” which he drew up the following statements occur :
“ These pictures . . . were the result of temptations and per¬
turbations, seeking to destroy imaginative power,by means of that
infernal machine called Chiaro Oscuro, in the hands of Venetian
and Flemish Demons, whose enmity to the Painter himself, and
to all Artists who study the Florentine and Roman schools, may
be removed by an exhibition and exposure of their vile tricks”;
and, again, of certain of his drawings he says that he wishes they
were “in Fresco on an enlarged scale to ornament the altars
and churches, and to make England, like Italy, respected by
respectable men of other countries on account of Art. It is not
want of Genius that can hereafter be laid to our charge.” Of
another picture he remarks : “ Hence Rubens, Titian, Correggio,
and all of that class are like leather and chalk. Their men are
like leather and their women are like chalk, for the disposition
of their forms will not admit of grand colouring. In Mr. B.’s
Britons the blood is seen to circulate in their limbs ; he defies
competition in colouring.” There is another distinct reference
in the same catalogue to his “ persecutors ”; describing another
of his pictures, he says that “Fortunately,or rather, providentially,
he left it unblotted and unblurred, although molested continually
by blotting and blurring demons/’ In regard to the catalogue
itself, he proclaims that “All these things are written in Eden.
The artist is an inhabitant of that happy country, and if every¬
thing goes on as it has begun, the world of vegetation and
generation may expect to be opened again to Heaven, through
Eden, as it was in the beginning ” (46). From these extracts,
it is obvious that Blake’s mental condition was one of marked

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exaltation ; in addition to the megalomaniacal fervour there is
quite definite evidence of influence by persecutionary ideas.
That the artist’s opinion of the pictures in his exhibition was
not shared by one at least of the critics of the time an extract
from the Examiner at that time makes quite clear. This paper
was well known for its outspokenness, and it may be remembered
that Leigh Hunt, who edited it, was imprisoned for having in
its columns described the Prince Regent as “ a fat Adonis of
fifty.” The writer describes Blake as “ an unfortunate lunatic,
whose personal inoffensiveness secures him from confinement,”
and he goes on to say : “ The poor man fancies himself a great
master, and has painted a few wretched pictures, some of which
are unintelligible allegory, others an attempt at sober character
by caricature representation, and the whole ‘blotted and blurred’
and very badly drawn. These he calls an Exhibition, of which
he has published a Catalogue, or rather a farrago of nonsense,
unintelligibleness, and egregious vanity, the wild effusions of a
distempered brain ” (47).

It was not only in this catologue that Blake made manifest
the morbid exaltation which characterised him during this
period. Subsequent to it there is ascribed to him what Mr.
Ellis describes as “ a misguided prose document,” entitled a
Public Address. Those who can say that it is not the product
of a “ distempered brain,” and who will, therefore, be unable
to pity the state of the unfortunate man, are left with the un¬
pleasant alternative of ascribing it to “ egregious vanity.” Such
passages as the following occur in this curious production :
“ Mr. Blake’s inventive powers and his scientific knowledge of
drawing are on all hands acknowledged.”—“ I do not shrink
from comparison in either relief or strength of colour with
Rembrandt or Rubens ; on the contrary, I court the comparison
and fear not the results.”—“ If all the princes of Europe, like
Louis XIV and Charles I, were to patronise such blockheads,
I, William Blake, mental prince, would decollate and hang their
souls as guilty of mental high treason.”—“ I do pretend to
paint finer than Rubens, or Rembrandt, or Titian, or Coreggio.”
There is a passage in this address which appears to show that
Blake was aware of the opinion which many held in regard to
his mental state. “ It is very true,” he says, “ what you have
said for these thirty years ; I am mad, or else you are ” (48).

This was about the year 1810, and of the following six years

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there does not appear to be any definite record. According to
Gilchrist he was still living in South Molton Street, “ in his
accustomed poverty, and, if possible, more than accustomed
neglect.” Apparently he continued his work during this time :
“Scores of MSS. were produced,” says Gilchrist, “which never
got beyond MS., and have since been scattered, most of them
destroyed or lost.” Gilchrist adds the significant comment—
“ He could find no publisher here for writing or design.” It is
greatly to be regretted that the information is lacking which
would throw light upon this period ; it may be that the exal¬
tation already noted may have been succeeded again for a
time by depression. A passage in Gilchrist seems to bear this
out. According to the biographer Blake kept very much to his
own house ; and for “ two years together [he] never went out at
all, except to the corner of the Court to fetch his porter ” (49).

In 1818, Blake became acquainted with Linnell the artist;
and the latter thus speaks of Blake as he found him at this
time : “ I soon encountered Blake’s peculiarities, and, somewhat
taken aback by the boldness of some of his assertions, I never saw
anything the least like madness, for I never opposed him spite¬
fully, as many did, but being really anxious to fathom, if possible,
the amount of truth which might be in his most startling asser¬
tions, generally met with a sufficiently rational explanation in
the most really friendly and conciliatory tone ” (50). From
which we may see that, even with all his anxiety, Linnell was
not always able to fathom the “startling assertions” of his
friend ; nor does he state that he was able to obtain more than
a “ sufficiently rational ” explanation of them. However, it
may suffice to note here that even such a champion as Linnell,
of the opinion that Blake showed no sign of madness, was
quick to perceive his " peculiarities.” Linnell introduced Blake
to an artist friend, John Varley, whom Gilchrist describes as a
“ remarkable man, of very pronounced character and eccentri¬
cities.” He was, in addition to being a landscape-painter, a
“ professional astrologer ” ; and he was, moreover, “ superstitious
and credulous.” It was the credulous Varley, who, placing
“ implicit and literal credence ” in Blake’s stories of his inter¬
course with the spirit world, encouraged him to make the
sketches of his “ visitants ” which are known as the “ Vision¬
ary Heads.” Allan Cunningham, who had his account from
Varley, thus describes their production : “ The most propitious

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time for those ‘ angel visits ’ was from nine at night till five
in the morning ; and so docile were his spiritual sitters that
they appeared at the wish of his friends. Sometimes, however,
the shape with which he tried to draw was long in appearing,
and he sat with his pencil and paper ready, and his eyes idly
roaming in vacancy ; all at once the vision came upon him, and
he began to work like one possessed ”(51). As might be
expected, Blake produced a varied assortment of portraits ;
among them one of the best known is that which has been
called the Ghost of a Flea. It is a fearsome object and worthy
of a place in the most lurid nightmare. During the time
occupied in completing the drawing, the flea told Blake, accord¬
ing to the credulous Varley, “ that all fleas were inhabited by the
souls of such men as were by nature blood-thirsty to excess,
and were, therefore, providentially confined to the size and form
of insects ; otherwise, were he himself, for instance, the size
of a horse, he would depopulate a great portion of the
country ” (52).

Other visions appeared to Blake at this time, and among
them was one of Satan. “ For many years,” said Blake, “ I
longed to see Satan. ... At last I saw him. I was
going upstairs in the dark, when suddenly a light came
streaming amongst my feet; I turned round, and there he was
looking fiercely at me through the iron grating of my staircase
window.” Blake, undaunted by the gruesome spectre, got a
piece of paper and sketched it. “ Its eyes were large and like
live coals, its teeth as long as those of a harrow,” says
Cunningham, “ and the claws seemed such as might appear in
the distempered dream of a clerk in the Herald’s office ” (53).
In addition to a deal of fantastic work such as this Blake did,
however, continue to produce other pictures of a very different
character, notably his illustrations of the Book of Job. These
were executed for his staunch supporter, Mr. Butts. Even
this patron, however, seems to have found Blake’s ways some¬
what trying. “ Even his old friend, Mr. Butts, a friend of
more than thirty years’ standing, the possessor of his best
temperas and water-colour drawings, and of copies of all of his
engraved books, grew cool,” says Gilchrist. “ The patron had
often found it a hard matter not to offend the independent,
wilful painter . . . The patron had himself begun to

take offence at Blake’s quick resentment of well meant, if blunt,

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advice and at the unmeasured violence of his speech when
provoked by opposition ” (54).

Much interesting information in regard to these later years
of Blake’s life is to be found in the Diary of Henry Crabb
Robinson. In one of the earliest of the entries relating to
Blake, and under the date 1810, he says : “ I amused myself
this spring by writing an account of the insane poet, painter,
and engraver, Blake” (55). Again, in 1811, he refers to
meeting Southey and says : “ Southey had been with Blake and
admired both his designs and his poetic talents. At the
same time he held him to be a decided madman. Blake, he
said, spoke of his visions with the diffidence which is usual
with such people, and he did not seem to expect that he should
be believed. He showed Southey a perfectly mad poem
called Jerusalem. Oxford Street is in Jerusalem.” In 1815,
the diarist records a remark made by Blake to Flaxman
to the effect that “ he had had a violent dispute with the
angels on some subject, and had driven them away ”(56). In
1825, Crabb Robinson met Blake, and from that period there
are numerous references to him in the diary. In December
of that year, the diarist records a conversation with Blake :
“ Shall I call Blake artist, genius, mystic, or madman ?
Probably he is all . . . He spoke of his paintings as

being what he had seen in his visions. And when he said

* my visions ’ it was in the ordinary unemphatic tone in which
we speak of every-day matters. In the same tone he said
repeatedly, ‘ The Spirit told me.’ I took occasion to say,

■ You express yourself as Socrates used to do. What resem¬
blance do you suppose there is between your spirit and his ? ’

* The same as between our countenances.’ He paused and
added, ‘ I was Socrates,’ and then, as if correcting himself,
said, ‘ a sort of brother. I must have had conversations with
him. So I had with Jesus Christ. I have an obscure
recollection of having been with both of them.’ Later Blake
remarked : * I have conversed with the spiritual Sun. I saw
him on Primrose Hill. He said, ' Do you take me for the
Greek Apollo?’ ‘No,’ I said, * that (pointing to the sky) is
the Greek Apollo. He is Satan’”(57). Later in the same
month, Robinson makes note of visits made by him to Blake,
who was then living at Fountain Court, Strand. The artist’s
circumstances were very straitened, and, says Robinson,

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“ nothing could exceed the squalid air both of the apartment
and his dress.” On one of these occasions, Blake spoke of
Milton appearing to him, and he stated also that he had had
his faculty of vision “from his early infancy.” In February,
1826, of another visit to Blake it is noted that the artist spoke
of having had much conversation with Voltaire, and when his
interlocutor asked him why he did not draw the forms of his
visitants he replied, “ It is not worth while. There are so
many, the labour would be too great.” On the same occasion
Blake remarked, “ I write when commanded by the spirits, and
the moment I have written I see the words fly about the room
in all directions” (58). In a letter to Wordsworth’s sister,
written in February, 1826, Crabb Robinson mentions Blake.
“ I gave your brother,” he says, “some poems in MS. by him,
and they interested him, as well they might, for there is
an affinity between them, as there is between the regulated
imagination of a wise poet and the incoherent outpourings of
a dreamer. He (Blake) has lived in obscurity and poverty, to
which the constant hallucinations in which he lives have
doomed him . . . He is not so much a disciple of Jacob

Bohme and Swedenborg as a fellow-visionary. He lives as
they did, in a world of his own, enjoying constant intercourse
with the world of spirits. He receives visits from Shakespeare,
Milton, Dante, Voltaire, etc., and has given me repeatedly
their very words in their conversations. His paintings are
copies of what he sees in his visions. His books
are dictations from the spirits” (59). In June of the same
year, the following entry occurs : “Called early on Blake. He
was as wild as ever, with no great novelty. He talked, as
usual, of the spirits, asserted that he had committed many
murders.”

Blake had continued to work during these latter years of his
life with the same industry that had ever characterised him.
Crabb Robinson mentions a large number of MSS., but many of
these appear to have been destroyed, and, during this period,
he produced—amongst other artistic works—the illustrations
of Dante. But, in 1826, his health was failing; there was
abdominal trouble, the nature of which—as far as can be judged
from the accounts which remain—was probably cancerous. In
his letters from 1826 onwards, Blake makes references to
such symptoms as acute pain, and “ that sickness to which

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there is no name,” and, at another time, he refers to his jaundiced
state. Writing to Linnell, who had suggested that he should
migrate to Hampstead, he says : “ 1 have thought and thought
of the removal. I cannot get my mind out of a state of terrible
fear at such a step. The more I think, the more I feel terror
at what I wished at first, and thought a thing of benefit and
good hope. You will attribute it to its right cause—intellectual
peculiarity, that must be myself alone shut up in myself, or
reduced to nothing. I could tell you of visions and dreams
upon the subject.” This was in February, 1827 ; he became
gradually weaker and died in August of the same year.*

* There appears to be some confusion in regard to the question as to whether
Blake was at one time an inmate of Bethlem Hospital. Brierre de Boismont's
account of a patient whom he describes as Blake the Seer appears almost obviously
to refer to William Blake, except that towards the end of it he speaks of him as
" a tall man.” William Blake was, however, short; according to Gilchrist he was
“ low in stature, not quite five feet and a half.” Timbs, in his English Eccentrics,
accepts de Boismont's statements as to Blake’s residence in Bethlem; and the
same writer says that Blake’s mind, about the period of his residence at Felpham,
“ was confirmed in that extraordinary state which many suppose to have been a
state of chronic insanity.” Dr. Charles Elam, in A Physician’s Problems, has a
description which he applies to this same Blake the Seer, and he adduces the
evidence of Dr. Wigan, who, however, speaks of the artist as having been "thirty
years in an asylum,” and as being a portrait painter. Mr. Ellis mentions the fact
that William Blake “ of the Prophetic Poems ” has been identified with this other
Blake, but he speaks of it as an error. Mr. E. G. O’Donoghue, the author of an
admirable history of Bethlem Hospital, informs me that he has been unable to
ascertain that Blake was at any time a patient there. There is no mention of
Blake having been a patient in that hospital by Gilchrist, Symons, Wilkinson,
Tatham, or by any of the other biographers as far as can be ascertained. Brierre
de Boismont refers to an article in the Revue Britannique dated July, 1823 (this
must be a mistake for 1825, as the Revue did not commence until then). The copy
of the Revue in the British Museum has the June and August numbers, but not the
one for July, so that it has not been possible in the meantime to ascertain from
what source the Revue obtained its information. In Bryan’s Dictionary of Painters
and Engravers there is, however, a reference to a B. Blake, who was a painter of
still life, birds, fish, etc., and who copied works of the Dutch painters. “ Little of
his history is known,” the account given of him there states : he was apparently
rather dissipated and a spendthrift. He is said to have died ” about the year 1830.”
Curiously enough there is no mention of this Blake in the Dictionary of National
Biography. Bryan also mentions a Nicholas Blake, an engraver, who illustrated
Hanway’s Travels in Russia, and published an edition of Pope’s poems in 1753.
This Blake is stated to have lived many years in Paris and to have died about the
end of the eighteenth century. Altogether the evidence is against the supposi¬
tion that Blake was a patient in Bethlem. Mr. O’Donoghue is making further
researches into the matter, and it will certainly be interesting to learn whether
anyone called Blake, who was an artist and an engraver, resided there during
the first quarter of the nineteenth century—or late in the eighteenth century.

[Brierre de Boismont, On Hallucinations, p. 83, Eng. trans, London, 1859.
Ellis, op. cit., p. 45. Gilchrist, op. cit.,vo\. i, p.315. Elam, Charles, A Physician s
Problems, pp. 299 and 336, London, 1869. Wigan, A. L., The Duality of the Mind,
pp. 125, 169, London, 1844. Timbs, John, English Eccentrics and Eccentricities,
p. 345, new ed., London, 1877. Wilkinson, Dr. J. J. Garth, Preface to Songs of
Innocence and Experience, London, 1839. Bryan, Michael, Dictionary of Painters
and Engravers, articles : "Blake,” London, 1S49; new cd., 1904.]

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III.

From the evidence which has been adduced it would seem
that no injustice is done when the statement is made that Blake
exhibited symptoms indicating marked mental instability. Yet
there are many who resent the application of the term
“insane” to him. It appears, however, to be rather a matter
of phraseology, for, while most of them admit the presence of
morbid mental symptoms, they do not wish to accept the logical
conclusion which such an admission leads to, namely, that the
person who does display such symptoms is of unsound mind.
The recognition of such disordered mental states when they
lead to some infraction of the legal code is admitted by all to
be a matter of importance, and the plea of non compos is readily
urged. Insanity has, however, usually to exhibit itself in
some outrageous or extravagant manner before it is admitted
as such by most laymen. Unless the conduct of the insane
person is annoying or detrimental to his neighbours, the latter
will not seek to restrain him ; but should the one “disordered
in his wits ” become troublesome, the aid of the alienist and the
assistance of the law will be speedily invoked. We can most
of us contemplate with a fair amount of equanimity the worries
and irritations to which others are subjected, but we soon
resent such troubles when they come our way. 11 Nous nvons
tons," says La Rochefoucauld, “assez de force four supporter
les viaux (Tautmi."

The recognition of the fact that such symptoms as those
exhibited by Blake are evidential of mental derangement is not
a matter of purely academic interest; nor is the assertion
that he was at times so greatly the victim of his unstable nervous
organisation as to merit the statement that he was definitely of
unsound mind made heedlessly or merely in a spirit of contra¬
diction. A great principle is at stake when we are asked to
admit that the hallucinations and delusions of any man—however
eminent—are not such, but that they are clear evidence of the
objective reality of what he sees and hears, and that therefore
the beliefs which he arrives at are rational and credible. It
has taken centuries even to initiate what we believe to be a
scientific conception as to the origin of such disorderly mental
processes, namely, that they are the outcome of deranged

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cerebral functioning. Primitive animistic beliefs in regard to
the malign influence of hostile spirits, which were held by our
early ancestors, and which still dominate the conduct of many
savage tribes, have slowly faded out of our scheme of causation.
Demoniacal possession, and its correlated horrors in regard to
the treatment of the insane, have been fought and driven out
inch by inch by the advancing forces of rational thought. Yet
still there are those who would cast all these gains away and
return to the halcyon days of those golden ages when human
blood had to be shed in order to propitiate the angry deities
who then ruled the minds of men, or to the times when men and
women had to be scourged and beaten until their suffering
frames should prove uncomfortable resting-places for the demons
who inhabited them. It is idle to say that this is an exaggerated
picture, and that there is no logical sequence between those
beliefs and the ones which are held by modern spiritualists, and
by those who maintain the veridical nature of Blake’s “visions”
and “ voices.” The continuance of such beliefs is too obvious
to need demonstration, and the recrudescence of certain popular
delusionary ideas is so marked as almost to make one fear that
there may be in the future a reversion to the belief in witches,
warlocks, and demons. Tylor, in his masterly survey of
primitive custom and belief, has noted this tendency to recru¬
descence; speaking of witchcraft,and “the persecution necessarily
ensuing upon such belief,” he says that “any one who fancies
from their present disappearance that they have necessarily
disappeared for ever must read history to little purpose, and has
yet to learn that ‘revival in culture’ is something more than an
empty pedantic phrase. Our own time has revived a group of
beliefs and practices which have their roots deep in the very
stratum of early philosophy where witchcraft makes its first
appearance. This group of beliefs and practices constitutes
what is commonly known as Spiritualism ” (60).

It has been noted above that the conflict of opinion in regard
to the question of Blake’s sanity is greatly a matter of phraseo-
logy. Those who maintain that he was of sound mind ascribe
to him symptoms and modes of conduct which are not usually
associated with the sane state. To some extent this has already
been made clear. It may not be uninteresting to exemplify
still further the descriptions given by such writers as Gilchrist,
Swinburne, and others who uphold the contention that Blake

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was sane, and to add also the testimony of those who take up
an opposite point of view.

Gilchrist, writing of the Marriage of Heaven and Hell , remarks
that there could not “well be a harder task than the endeavour
to trace out any kind of system, any coherent or consistent
philosophy, in this or in any other of Blake’s writings ” ; while
of the America he says : “ It is verse hard to fathom, with far
too little nature behind it or backbone, a redundance of mere
invention—the fault of all this class of Blake’s writings; too much
wild tossing about of ideas and words.” And, further, Gilchrist
states that “ to men of the world, his was a mind which, whether
judged by his writings or his talk, inevitably seemed scarcely a
sane, still less a trustworthy one ” (61).

Swinburne, full of sound and fury, lays about him so vigorously
that a good many of his blows fall upon him whom he is defend¬
ing. “Blake had,” says Swinburne, “a devil, and its name was
faith.” For Swinburne the “vagaries and erratic indulgence in
the most lax or bombastic habits of speech become hopelessly
inexplicable ” after the excellence displayed by Blake in some
of his poems. He comments scathingly on the “chatter” about
Blake’s madness, but previously he has spoken of his “ fitfully
audacious and fancifully delirious deliverance” and of his
“ eccentric and fitful intelligence.” By regarding Blake rather
as “a Celt than as an Englishman” he thinks it is not difficult
to understand from whence he derived his “ amazing capacity
for such illimitable emptiness of mock-mystical babble as we
find in his bad imitations of so bad a model as the Apocalypse.”
Again, of the prophetic books, Europe and America , he says
that there is “ more of the divine babble which sometimes takes
the place of earthly speech or sense, more vague emotion with
less of reducible and amenable quality than in almost any of
these poems.” He speaks of the “ insane cosmogony, blatant
mythology, and sonorous aberrations of thoughts and theories.”
“ Sickness or sleep never formed such savage abstractions, such
fierce vanities of vision as these ; office and speech they seem to
have none ; but to strike or clutch at the void of air with feeble
fingers, to babble with vast lax lips a dialect barren of all but
noise, loud and loose as the wind.” However, though Blake was
“ violent and eccentric at times,” Swinburne seemed to be able
to derive comfort from the conclusion that his “aberrations were
mainly matters of speech and writing” (62). If the case for

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Blake’s sanity had only Swinburne as its advocate, it would
indeed be in a parlous state.

Another defender of Blake against the imputation of insanity,
Dr. Greville Macdonald, is evidently of the opinion that he has
suffered almost as much at the hands of those who wish to
exculpate him from such an accusation as from those who hold
the opposite opinion. “ Blake was undoubtedly mad,” he said,

“ if we are to believe all that his apologists wrote to prove the
contrary.” He opposes the views of Ellis and Yeats in regard
to the interpretation which they have attempted to give of the
involved prophetic books : they “ invite us to substitute an
absolutely unintelligible mysticism for some of the grandest
symbolic writing the world has ever produced.” In another
place he says: “I am not sure that consistency is not the finest
test of sanity, just as incoherence is the final proof of aberration”
(63). Without pausing to discuss the utility or the validity of
such a test, it will be interesting to record the criticism by
another apologist, Mr. Arthur Symons, of Blake’s The Four Zoas.
“ It is,” he says, “ without apparent cohesion or consistency” ;
whilst the America is “the most vehement, wild, and whirling
of all Blake’s prophecies” (64). But Dr. Macdonald’s descrip¬
tions of some of Blake’s writings are sufficiently suggestive that
—even in his opinion—all was not well. The Jerusalem is
“ indeed a strange medley of passionate poetry and catalogued
bathos. We have pages and pages of stuff that were not worth
reading, but for the shining gems hidden among the rubbish.”
And again he remarks : “ If the apparent purposelessness of our
prophet’s vast weediness seems often to justify the verdict of
madness, we are again and again, while striving to find passage
through the jungle, driven to exclaim that Blake’s so-called
madness is infinitely greater than our sanity.” Under the
circumstances it is not surprising that Dr. Macdonald feels
constrained to admit that “Blake’s small power of criticising his
own u'ork implies some lack of mental balance” (65).

Mr. Symons has to confess that he also finds much of what
Blake has written quite unintelligble : “ Of the myth itself,” he
says, “ it must be said that, whether from defects inherent in it
or from the fragmentary state in which it comes to us, it can
never mean anything wholly definite or satisfying, even to those
minds best prepared to receive mystical doctrine.” Ifacertain
passage by the same w'riter is truly descriptive of Blake it

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reveals in him a characteristic symptom of many forms of
insanity when they have proceeded to the length of obviously
diminished self-control: “ With Blake,” he says, “ belief and
action were simultaneous.” However, in another place Mr.
Symons says that “ with Blake, as with all wise men, a mental
decision in the abstract had no necessary influence on conduct ”
(66). Obviously—unless in Mr. Symons’pyschological scheme
“belief” is not a “mental decision in the abstract”—the
passages just quoted contradict one another.

Mr. Joseph Wicksteed, who surmises that “ the crude charge
of insanity which used to be levelled against Blake is surely
almost dead,” admits that “ there remains a too well-founded
charge of waywardness and extravagance, such as cannot be
attributed to normal processes of mind, even in the blast
furnace of genius.” “ Blake’s undoubted abnormal mentality was
controlled by a not less remarkable faculty for artistic, and even
philosophic, unity and coherence. In one sense he was further
removed from the lunatic than those who have less cerebral
peculiarity. And even if there were real lapses of control,
these were rather literary than practical. His actual life seems
to have been conspicuous for its sanity ” ; and Mr. Wicksteed,
too, finds that Blake is “often abysmally unintelligible.” We
may apparently say that a person’s mental processes are not
normal, that he has some “cerebral peculiarity,” and that in
his conduct he exhibits “lapses of control,” but we must not
use the accursed word “insanity” to describe his “abnormal
mentality” !

In an article which deals specifically with the question of
Blake’s mental state, and which he entitles “ The so-called
‘ Madness’ of William Blake,” Mr. Wicksteed does not seem to
improve the case for the defence. In it he informs us that
with Blake “ expression was a refuge from obsession ” ; and
further he states that “ Blake’s peculiar position is that he takes
11s through the abnormal and morbid in the subjective world.
He is almost alone in having entered the fiery caverns of the
maniac and not been mad” (67). It is difficult to comment
upon such expressions as Mr. Wicksteed uses here. He appears
to be discussing a species of “ psychology,” which, however
useful for literary purposes it may be, is much too weird and
wonderful for plain and practical people who have to do what
they can to understand the workings of disordered brains, and

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to suggest appropriate treatment for the condition. Of course,
it is almost an insult to mention the word cerebrum or brain to
any devotee of these strange systems of transcendental psycho¬
logy. By some “ occult ” or “ mystic ” methods the workings
of the “immaterial substance” which hovers like an aureole—
or like a mephitic vapour—around the skull, or around the
brain, or which settles on the pineal gland of the Cartesian,
can be much more easily understood than by the study of
the vulgar and commonplace processes of cerebral physiology,
or of nervous metabolism !

Mr. G. K. Chesterton’s attitude in regard to the question of
Blake’s sanity or insanity is rather difficult to define,as the follow¬
ing extracts show. “ If we ask," says Mr. Chesterton, “ whether
there was not some madness about him, whether his naturally
just mind was not subject to some kind of disturbing influence
which was not essential to itself, then we ask a very different
question, and require, unless I am mistaken, a very different
answer. When all Philistine mistakes are set aside, when all
mystical ideas are appreciated, there is a real sense in which
Blake was mad.” The same writer notes that while Blake was
at Felpham his “ eccentricity broke out on another side. A
quality that can frankly be called indecency appeared in his
pictures, his opinions, and to some extent in his conduct" (68).
It is a little difficult, however, to follow the flights of fancy of
certain of these amateur alienists. Mr. Chesterton, for instance,
goes on to say that it was “ an idealistic indecency.” As it was
evinced in Blake’s pictures, opinions, and conduct, one would
have thought that it might certainly have been described as
being, on the contrary, decidedly realistic. It was Hobbes who
made the remark about words being wise men’s counters ; and
the saying concludes with a statement as to the value they
possess to those who are not quite so wise.

Having said that Blake was mad, Mr. Chesterton later
comes to the conclusion that “ in other words, Blake was not
mad ; for such part of him as was mad was not Blake.’’ It
was “ an alien influence” that brought about the mental change
in him. Then back we go again to a statement that Blake
was mad. “If Blake had always written badly he might be
sane. But a man who could write so well and did write so
badly must be mad.” . . . “I firmly believe that what did

hurt Blake’s brain was the reality of his spiritual communica-

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tions ... I say he was mad because his visions were
true.” And yet once again, in referring to Blake’s reason : “ It
had been broken (or cracked) by something ; but what there
was of it was reasonable ” (69). No further comment will be
made regarding these statements, except to quote another
passage from Mr. Chesterton’s essay, which, with merely a
verbal alteration, is singularly applicable in the present instance.

The truth is,” he says, “ that beyond their scientific ideas
they have not the absence of ideas but the presence of the
most vulgar and sentimental ideas that happen to be common
to their social clique ”(70). If herein we read “pseudo¬
scientific ” the description is sufficiently appropriate.

Still another commentator, Mr. Alfred T. Story, has given
his “ explanation ” of the psychological puzzle—for such it has
certainly been to most of the apologists—of Blake’s mental
processes. Mr. Story protests against the assertion that Blake
was insane, but the phrasing of his verdict in the matter might
well be accepted as evidence of mental unsoundness. “ There
was,” he says, “ a want of balance betwixt the spiritual or
visionary faculty and the power of expression . . . The

brain becomes heated under the fervour of vision
With the continued rush of blood to the brain the whirl of
thought becomes terrific, the visions hustle one upon another,
the demons ‘ howl ’; there is a chaos of sound and fury. The
frenzied prophet, however, faithful to his trust, still labours
with the weak mortal instrument at his command to set down
the revelation. What wonder if he be at times incoherent,
incomprehensible? The marvel would be if he were not.” It
is a fairly comprehensive list : howling demons, hustling visions,
chaos of sound and fury, terrific whirling thoughts, incoherence,
incomprehensibility—but no insanity ! “ Such, in brief,” con¬
tinues this writer, “ is all that Blake’s alleged insanity amounted
to.” The candid critic will admit that, on Mr. Story’s own
showing, it appears to amount to a good deal. Yet it was not
insanity, it was “ lack of mental balance arising from a
preponderance of the spiritual or imaginative faculty” (71).

In France, the work of Blake has aroused much interest.
There, too, certain writers have felt impelled to take up the
cudgels on his behalf to defend him against the imputation of
mental disorder. For instance, M. P. Berger, in an extensive
study of Blake’s Mysticismc et Potfsie, says that “ Sans doute

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l’accusation de folie ne sera plus sur nos l&vres,” but he is con¬
strained to add “ Nous avons conscience de la masse de son
Edifice qui est rest^e dans l’obscurit£, des parties nombreuses
dont tout art est absent, parce que le symbolisme Ten a chass£.”
M. Berger notes, too, the decadence in Blake’s poetical powers ;
he expresses gracefully and in poetical terms the truth that
Blake’s energies were sapped by a morbid mental process.
This inference is not an unfair one, as M. Berger’s words show :
“ Nous l’avons trouv£ infini dans ses ideals, limits dans ses
moyens par son mysticisme meme, germe morbide qui lui a
donn(S son charme ind^finissable mais qui l’a tu£a la fin comme
le ver rongeur tuait sa rose malade, apres lui avoir donnd la
m^lancolie gracieuse de sa courbe retombante” (72).

M. F. Benoit (73), who also protests vehemently against the
suggestion of insanity, admits the curious mental vicissitudes,
the visions, and the voices, and notes the sudden changes of
mood from placidity, tolerance, indifference, almost from
meekness: then “ l’instant d’apres, le meme homme nous
apparait le plus entier, le plus irritable, les plus brutal des
disputeurs. Le moindre objection le met en fureur ; la seule
apparence du doute l’exaspere ; il contredit pour contredire,
jusqu’a s’enteter dans l’absurde, jusqu ’4 d^naturer sa pensee par
les plus folles extravagances.” M. Benoit thinks, however, that
Blake is an exceptional case ; a conclusion to which he would
not have come if he had had only a moderately extended
acquaintance with the symptoms displayed by those suffering
from mental disorder. M. Benoit is perhaps a little unkind to
us when he remarks : “ Si Stranges que soient ses singularity
mentales, elles ne font exception ni dans son siecle ni dans son
pays!” Nor does he strengthen his case for Blake when he
goes on to say that he was contemporary with Swedenborg,
Mesmer, Cagliostro, and Cosway, for in their records we see
clearly insanity or imposture. M. Benoit thinks that neurolo¬
gists and alienists cannot bring the case of Blake into the
category “ des infirmes d’esprit de corps qui forment la clientele
ordinaire de leurs laboratoires.” Wherein one may humbly
opine that M. Benoit is in error. Whilst agreeing with him
that those mentioned should accord Blake a careful and earnest
study, the present writer is doubtful whether his essay in that
direction will be found “ tecond en conclusions curieuses et
suggestives ”!

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IV.

It is apparently the opinion of many admirers of Blake that
no one who, after a critical examination of his life and works,
comes to the conclusion that he undoubtedly suffered from
mental derangement, can possibly still have affection for him
as a man, or admiration for him as an artist or as a poet. If
such a belief is held, then this much is certain—that it is
based upon as incomplete a knowledge of facts as a goodly
number of other beliefs are. The statement that a person is
insane may—and often does—militate against his credibility as
a witness, but it does not detract from the aesthetic value of
his poetical or artistic productions. If we knew that the
sculptor of the Venus of Milo suffered from delusional insanity
we should not abate a whit our admiration for that superb
work of art; if, however, he had asserted that the goddess
herself had sat to him as a model, we should ask to be allowed
to posit our distinct doubts as to the truth of his statement.
In the same way with Blake, we do not attempt to deny the
excellence of much of his work, but when we are required to
believe that supernatural agencies exerted their influence over
him in vision and by audition, we have to remark that certain
gratuitous assumptions are involved in the statement. In the
first place, it is assumed that these agencies exist, and this—
despite the assertions of numerous credulous spiritualists—is
far from being accepted by those who have given the matter
serious study ; and secondly, even granting the hypothesis that
he was so influenced, we are asked to believe that these super¬
natural agencies exerted themselves to produce a deteriorative
effect upon his productions, for, as his history proves, the more
he was influenced by them the more disorderly and incoherent
did his work become ; in much the same way as the results
obtained by the spiritualistic medium are frequently seen to be
chaotic designs or puerile babble. If the automatism were to
take the form of that which is associated with the epileptic
state and were to be accompanied by homicidal or other noxious
acts, the devotees would soon flee from the presence of the very
unhappy medium or they would seek to restrain, vi et anti is,
any further exhibitions of his supernatural powers.

It will, perhaps, be of interest to cite the opinions of some of
those who, while realising the artistic and poetic powers of

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Blake, have not been in that condition where passion and
sentiment overwhelm critical ability, and who have consequently
admitted the presence of mental disorder in Blake. Tatham

(74) , who knew Blake, tells us that he was “a subject of much
mental temptation and mental suffering, and required sometimes
much soothing” ; he speaks of his “ eccentric and elastic mind,”
and of his poetry he says that it was “ mostly unintelligible.”
As to Blake’s visions and voices he remarks : “ He said that
he was the companion of spirits who taught, rebuked, argued,
and advised with all the familiarity of personal intercourse.
What appears more odd still was the power he contended he
had of calling up any personage of past days, to delineate their
forms and features, and to converse upon the topic most
incidental to the days of their own existence.” Tatham’s
comment upon this is : “ How far this is probable must be a
question left either to the credulity or the faith of each person”!

(75) . It is not possible to leave the matter there. The
credulous believer has been so often the victim of the schemer
and the dupe of the charlatan that it is necessary to examine
with whatever powers of exact scientific investigation we have
attained to in the process of our evolution, any claims to the
control of supernatural agencies, and in the same spirit must
we deal with the asseverations of “ brain-sick ” visionaries.

Dr. Malkin who, too, knew Blake, writing in 1806, says
that he possesses “ merit, which ought to be more conspicuous,
and which must have become so long since, but for opinions
and habits of an eccentric kind ” ; and further, of Blake’s blank
verse: “ The unrestrained measure, however, which should warn
the poet to restrain himself, has not unfrequently betrayed him
into so wild a pursuit of fancy as to leave harmony disregarded,
and to pass the line prescribed by criticism to the career of
imagination,” while, in another place, he speaks of Blake’s
“ singularity,” of his “ enthusiastic and high-flown notions on
the subject of religion,” and of the “ hue and cry of madness ”
which have pursued him (76).

Charles Lamb, writing to Bernard Barton in 1824, speaks of
Blake’s “ wild designs ” to Young’s Night Thoughts : “ He paints
in water-colours marvellous, strange pictures, visions of his
brain, which he asserts that he has seen. They have great
merit.” After commending certain of Blake’s poems, Lamb
adds : “ The man is flown, whither I know not, to Hades or a

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mad-house” (77). As we have already noted, Southey
described Blake to Crabb Robinson as a “decided madman.”( 2 )
That was in 1811, after Southey had paid a visit to Blake. In
The Doctor , written more than twenty years later, Southey
speaks of him as “ that painter of great, but insane genius,”
and again as "this insane and erratic genius” (78). Words¬
worth describes certain of his poems as “ undoubtedly the
production of insane genius,” and he was not an unapprecia¬
tive critic, for he adds : “ There is something in the madness of
this man which interests me more than the sanity of Lord
Byron and Walter Scott ” (79). John Thomas Smith, Keeper
of the prints and drawings in the British Museum, in a
biographical sketch of Blake included in Nollekens and his
Times , published in 1828, speaks of him as bearing a “ stigma
of eccentricity,” and says that he was “ supereminently endowed
with the power of disuniting all other thoughts from his mind,
whenever he wished to indulge in thinking of any particular
subject, and so firmly did he believe, by this abstracting power,
that the objects of his compositions were before him in his
mind’s eye, that he frequently believed them to be speaking to
him ” (80J.

Dr. Richard Garnett says of Blake that “ in ancient times,
and perhaps in some countries at the present day, he would
have been accepted as a seer ; in his own age and country the
question was rather whether he should be classed with vision¬
aries or with lunatics. A visionary he certainly was, and few
will believe either that his visions had any objective reality, or
that he himself intended them to be received merely as
symbols . . . He confused fancy with fact ; unquestion¬

ably, therefore, he laboured under delusions.” Dr. Garnett
does not appear, however, to think that Blake’s condition could
be described as one of insanity ; but his interpretation of the
term “ insane ” differs from that given to it by the judicial
authorities and by alienists. Few of either of these would
agree with Dr. Garnett when he goes on to say that, for
example, “ Prince Polignac brought the monarchy of the
Restoration to ruin in deference to imaginary revelations
from the Virgin Mary, yet no court of law would ever have
placed him under restraint ” (81). Dr. Garnett, however, notes
the gradual dwindling of the poetic faculty in Blake as the
artistic grew : “ There is less of metrical beauty, and thought

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and expression grow continually more and more amorphous,”
in the later poems. The Auguries of Innocence seem “little
remote from nonsense,” while of the Descriptive Catalogue he says
that it is “ crammed with statements far more significant than
Blake’s visions of a condition of mental disorder ” (82). On
the whole, it would perhaps have been more fitting to place
Dr. Garnett among the “philosophic doubters.” However, he
has been classified by some as an opponent of the view that
Blake was sane, so that his testimony may be allowed to
remain in the position allocated to it.

Mr. de Selincourt discusses at some length the dispute in
regard to Blake’s sanity. “ Was Blake mad ? The question is,”
he says, “ unpopular, yet all the vociferation of Blake’s admirers
has not been able to silence it. Those who defend Blake’s
sanity with the greatest fervour are often more compromising
in their statements than his direct opponents.” As to Blake’s
assertions of his visionary powers, Mr. de Selincourt mentions
the names of Isaiah and of Ezekiel and says : “ Blake’s visions
can never come to be recognised as based upon the same order
of spiritual insight as theirs ”—[It is, indeed, difficult to see why
such an arbitrary distinction should be made between one set
of visions and another !]—“ but if they cannot, while yet to Blake
himself it is a matter of triumphant conviction that they can,
and if this false conviction is a ruling conviction of his life, I
do not see that his admirers have any serious right to complain
if the charge of madness is brought against him.” The “ entire
mystical mechanism of the Prophetic Books, with its gigantic
dramatis personce, its geography that violates the laws of space,
its history that neglects the passage of time, its unexampled
fusion of violence and vagueness in almost every department of
thought, is a mere fungus of mind.” “ With every allowance
for the unintelligibility of the language, its unrelieved intensity is
a sufficient test; the normal mind cannot assimilate more than
two pages of Blake’s prophecy without sensations approaching
nausea.” Mr. de Selincourt maintains that Blake was guilty of
“ self-deception so convincing that it transmits itself to many
of his readers. It was a mental obsession by which his whole
life . . . was coloured. It was a kind of madness” (83).

It is hardly justifiable, however, to use the term self-deception
in this connection, at least, if it is to be associated with any
sense of guilt or wilfulness. It would be more fitting to say

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that there was misinterpretation. Blake was the victim of his
tyrannous organisation: his consciousness was not able to
interpret correctly the vague stirrings of his subconsciousness.
Just as an error of refraction gives rise to faulty vision, so disorder
in certain cerebral cell-areas leads to incomplete or uncorrected
action in others, for example, in hallucinations and delusions
such as Blake experienced. That many of Blake’s readers have
taken him at his own valuation, and have consequently been
deceived into believing that his hallucinations and delusions
were real visions and well-founded beliefs is undoubtedly true.
In practice it is convenient to draw a distinction between the
hallucinations which are consistent with sanity—where the
person has insight into his condition, and realises that the hallu¬
cinations are subjective, that they are “ shadows, not substantial
things ”—and those which are associated with insanity. But
this distinction does not imply any difference in causation ; it
is really quite arbitrary. Yet certain writers have adopted the
same attitude as Mr. de Selincourt in regard to this question—
notably Brierre de Boismont—but the differentiation is at
bottom sentimental rather than scientific.

Mr. Sturge Moore has noted the diminution of Blake’s
poetical ability : “ His stock of images steadily perished, losing
in fineness and vividness as the subtler shades of all that in
youth he had been so eagerly enchanted by wore out in his
vision-laboured mind.” As to Blake’s Myth and his Prophetic
Books, Mr. Moore says that the “ psychology is confused and
ugly,” while “ the language he employs grows more and more
monotonous and exasperating, since all aesthetic control over it
is abandoned, even when he does not write subconsciously at
the dictation of visions endowed with only part of the faculties
of their amanuensis. Tedious repetitions of every kind
abound.” The Prophetic Books are, the same writer remarks,
“ very poor literature,” and “ though a man possessed by great
themes insecurely grasped may write confusedly, no man not
mad, having definite and important ideas to convey, would so
impenetrably have wrapped them up.” To Blake’s “ hopeful
editors ” Mr. Moore puts the query : “ Is it really conceivable
that thoughts should be clear in a mind that could choose to
express them in words so far wrested from their common use,
or in such a code of symbols as Blake’s ? ” (84).

Ireland comments on the similarity between Blake and

LXI. 16

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Swedenborg. “ Both,” he says, “ had a sublime opinion of
their own merits. Both were deeply religious ; both were
mystics who sought for new light in the inner sense of the
Scripture, and believed that they conversed with the spirits of
the departed.” He points out that the necessity of working
for his daily bread no doubt prevented Blake from giving
himself up entirely to the ideal as Swedenborg did ; and he
adds : “ As it was, his conduct was eccentric and imprudent,
sometimes extravagant to the very verge of insanity, if not
beyond it ” (85).

Maudsley, discussing hallucinations and illusions, states that
“ mental representations so intense as to become mental
presentation is a faculty of mind apt especially to be met with
among certain artists.” In this connection he mentions Blake.
“It was very remarkable,” he says, “in that strange and
eccentric genius, William Blake ; he used habitually to see his
conceptions as actual images or visions” (86).

It is difficult to realise how any unprejudiced person who
considers the evidence in Blake’s case can arrive at any other
conclusion than that he exhibited mental disorder. There is
no gainsaying the statements made by one writer who summed
up the evidence and gave his verdict in the following terms :
“ On an analysis of an estimate arrived at by these critics it
will be discovered that, while one defines him as an eccentric,
another as a visionary, a third as an enthusiast, a fourth as a
superstitious ghost-seer, all feel it expedient to mollify or to
apologise for modes of action inconsistent with the habits of
other healthy men ; it may be safely affirmed that if he was
not insane in conduct, Blake betrayed undoubted symptoms of
his mental malady in painting ” (87). Even Blake’s conduct,
however, was influenced by the imaginary voices and the
morbid delusions from which he suffered ; indeed, it is unduly
to limit the definition of the term conduct if we exclude from
it such acts as those of writing and of painting.

Though the prevailing state with Blake was one of exalta¬
tion and belief in his own capabilities, there were also periods
of extreme depression, and the condition may, with little doubt,
be classified as one of maniacal-depressive insanity. The
fluctuations in his mental condition were so marked as to be
in themselves sufficient evidence of marked nervous instability,
and these alternations were so pronounced as to be inconsistent

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with the normal periodicity which is to be noticed in those
whose sanity is not impugned. When, too, we find that in
addition to these alternations there is evidence of diminished
control—as shown in undue excitability and impulsive violence,
of hallucinations of sight and hearing, and of delusions of
persecution—there is no doubt that the boundary which
separates sanity from insanity has been crossed. Those who
protest against this plain statement do not seem to realise
that they do Blake less than justice. They would hold him
responsible for all his vagaries rather than allow a verdict of
non compos. Chiefly this is so in order that the vague,
mystical element in his work may be imputed to some vague
supra- or extra-natural power instead of to the disorderly
functioning of unstable nerve-tissue, or to misunderstood organic
reflexes. These nervous disorders are obscure enough even
when they are considered apart from the veiling mystery in
which so many love to hide them ; it is not, therefore, neces¬
sary to invoke occult powers, and by so doing to render the
subject nebulous and impenetrable. Still less is it wise to
place behind the disease of insanity a Mumbo-Jumbo, which has
to be invoked, or a Raw-head and Bloody-bones, which has to be
exorcised.

“ Great is truth, and mighty above all things,” and we may
add the words of Francis Bacon wherein he says that “ it shall
prevail.” That Blake was endowed with great abilities it has
herein been frankly admitted, but that such an admission
entails a blind and uncritical adherence to the view that every¬
where and at all times he exhibited the attributes of genius in
his works is as frankly denied. With the opinion of one who,
while admitting Blake’s "gift of imaginative intensity,” yet
realised that he “ fell short of completeness,” we may fittingly
conclude : “ There is small profit in that overpraise, even of
the dead, to which a proverb that has sheltered many a knave
invites us. Blake, at any rate, is great enough to bear nil nisi
verum for his epitaph ” (88).

(’) Blake thus elegantly expressed his sentiments :

“The only man I ever knew
Who did not almost make me spue
Was Fuseli.”

(*) Vide supra, p. 224.

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References.

(1) Symons, Arthur.— William Blake, p. 25, London, 1907; but
see also Ellis, Edwin J., The Real Blake , p. 5, London, 1907.

(2) Ellis.— Op. cit >, p. 5.

(3) Idem. — Op. cit., p. 4.

(4) Gilchrist, A .—Life of Blake, vol. i, p. 55, London, 1862.

(5) Tatham, F .—Life of William Blake, p. 3 (included in The Letters
of William Blake, edited by A. G. B. Russell, London, 1906).

(6) Gilchrist.— Op. cit., vol. i, p. 59.

(7) Morel, B. A .—Traite des Deginlrescences, p. 5, Paris, 1837.
Maudsley, Henry .—Pathology of Mind, p. 114, 3rd edit., London,
1879. Lombroso, C. —The Man of Genius, p. 13, London, 1891.

(8) Ellis.— Op. cit., p. 3.

(9) Gilchrist.— Op. cit., vol. i, p. 7.

(10) Ellis.— Op. cit., p. 16.

(11) Gilchrist.— Op. cit., p. 10.

(12) Ellis.— Op. cit., pp. 67-82.

(13) Idem. — Op. cit., p. 85.

(14) Idem. — Op. cit., p. 116.

(15) Swinburne, A. C.— William Blake, p. 227, 1906 edition.

(16) Gilchrist.— Op. cit., vol. i, p. 91.

(17) Ellis.— Op. cit., pp. 48-49.

(17A) Hind, Arthur M .—A Short History of Engraving and Etching,
p. 220, London, 1911. See also Henry G. Hewlett, “Imperfect
Genius: William Blake,” in Contemporary Revieiv, October, 1876,
and February, 1877.

(18) Ellis.— Op. cit., p. 181.

(19) Urizen: The Poetical Works of William Blake, vol. i, p. 344,
edited by E. J. Ellis, London, 1906.

(20) The Poetical Works of William Blake, vol. i, pp. 348, 355.

(21) Ibid., vol. i, p. 395.

(22) Gilchrist.— Op. cit., vol. i, p. 117.

(23) The Letters of William Blake, p. 57.

(24) Ibid., p. 68.

(25) Ibid., p. 70.

(26) Ibid., p. 72.

(27) Ibid., p. 75.

(28) Ibid., pp. 86, 88, 90-92.

(29) Ibid., p. 106.

(30) Swinburne.— Op. cit., p. 38.

(31) Poems, vol. i, p. 481.

(32) Ibid., p. 484.

(33) Ibid., p. 527 ; and see Ellis, op. cit., p. 221.

(34) Ellis.— Op. cit., p. 221.

(35) Gilchrist.— Op. cit., vol. i, p. 177.

(36) Swinburne.— Op. cit., pp. 39, 40.

(37) Letters, p. 134-

(38) Ellis.— Op. cit., p. 355.

(39) Gilchrist.— Op. cit., vol. i, pp. 192, 195.

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(40) Letters , p. 169 et set/.

(41) Ibid., p. 187.

(42) Ellis.— Op. cit., p. 250.

(43) Idem.—Op. cit., p. 255.

(44) Gilchrist.— Op. cit., vol. i, p. 225.

(45) Ellis.— Op. cit., p. 256.

(46) Idem. — Op. cit., pp. 285, 288, 289, 291.

(47) The Examiner , September 17th, 1809. (Quoted by Symons,
op. cit., pp. 199-200.)

(48) Ellis.— Op. cit., pp. 300 et seq.

(49) Gilchrist.— Op. cit., pp. 244-246.

(50) Symons.— Op. cit., p. 222.

(51) Cunningham, A.— Lives of Eminent British Painters , “Blake.”

(52) Varley, John.— A Treatise on Zodiacal Physiognomy, p. 54,
London, 1821. Symons, op. cit., p. 353.

(53) Cunningham.— Op. cit., “ Blake.”

(54) Gilchrist.— Op. cit., vol. i, p. 282.

(55) Robinson, Henry Crabb.— Diary, Reminiscences, etc., 3rd edit.,
vol. i, p. 156, London, 1872.

(56) Idem. — Op. cit., pp. 176, 247.

(57) Idem. — Op. cit., vol. ii, pp. 7-9.

(58) Idem. — Op. cit., vol. ii, pp. 10, 15.

(59) Idem. — Op. cit., vol. ii, p. 18.

(60) Tylor, E. B.— Primitive Culture , vol. i, p. 141, 4th edit.,
London, 1903.

(61) Gilchrist.— Op. cit., vol. i, pp. 78, 109, 317.

(62) Swinburne.— Op. cit., pp. 5, 11, 209, pref. vi, etc.

(63) Macdonald, Greville.— The Sanity of William Blake , pp. 9-10,
24, London, 1908. See also “William Blake, the Practical Idealist,”
in The Vineyard, November, 1912, p. 100.

(64) Symons.— Op. cit., pp. 97, no.

(65) Macdonald.— Op. cit., pp. 39-40.

(66) Symons.— Op. cit., pp. 75, 140, 171

(67) Blake’s Vision of the Book of fob, by Joseph H. Wicksteed, M.A.,
pp. 14, 26. “The So-called Madness of William Blake,” in The Quest,
October, 1911.

(68) Chesterton, G. K.— William Blake, pp. 72, 76, 77.

(69) Ibid., pp. 83, 93.

(70) Ibid., p. 56.

(71) Story, Alfred T.— William Blake, pp. 75-76 (London, 1893).

(72) Berger, Pierre.— William Blake, Mysticisme et Pocsie, p. 434,
Paris, 1907. (An English translation has recently been published.)

(73) Benoit, F.— Un Maltre de PArt, 1906, pp. 26, 37, 43, 49, 69.

(74) Tatham.— Letters, pp. 31, 32, 41.

(75) Ibid., p. 19.

(76) Malkin, B. H.— A Fathers Memoirs of his Child, pp. xi, xxiii,
London, 1806.

(77) Letters of Charles Lamb, vol. ii, p. 176, London, 1886. Life
of Lamb, by E. V. Lucas, vol. ii, p. 125.

(78) Southey, R.— The Doctor, pp. 473, 476, 1849 edit.

(79) Gilchrist.— Op. cit., vol. i, p. 2.

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(80) Smith, John Thomas.— Nolkkens and his Times , vol. ii; and
see Symons, op. at., pp. 357, 363.

(81) Garnett, Richard, LL.D.— William Blake , pp. 73-75, London,
1895.

(82) Idem.—Op. cit., pp. 31, 48, 57.

(83) de Selincourt, Basil.— William Blake , pp. 56, 62, 64, 68, 168.

(84) Moore, T. Sturge.— Art and Life , pp. 202-206, London, 1910.

(85) Ireland, W. W.— Through the Ivory Gate , pp. 130-131, Edin¬
burgh, 1889.

(86) Maudsley, Henry.— Natural Causes and Supernatural Seemings,
p. 197, London, 1897.

(87) Mad Artists, by Dr. W. F. A. Browne. Journ. of Psych. Med.
and Ment. Pathology (new series), 1880, vol. vi, pt. i, p. 45.

(88) Quarterly Review , January, 1865, p. 7, by J. Smetham. See
Berger, op. cit., p. 442.

The Luetin Test in Parasyphilis. By D. Maxwell Ross,
M.B., Ch.B.Edin., Assistant Physician, Royal Asylum,
Edinburgh.

DURING the spring of this year, my friend Lieutenant
Crocket, R.A.M.C., obtained, through the kindness of Dr.
Noguchi, a small supply of luetin, and with this he carried
out a series of tests, to which he was anxious to add some
observations on its use in mental cases. By permission of
Dr. G. M. Robertson he was able to examine a series of cases
in Morningside Asylum, and I was fortunate in being asked to
co-operate with him. Owing to our small supply of luetin, the
number of tests done was necessarily limited, and we intended
carrying our observations further when Crocket was called
away to duty. Only a short time ago the sad news of his
death in action was received, and it is largely on this account
that I venture to place on record so small a number of
observations.

In 1911, Noguchi reported, in the fournal of Experimental
Medicine, that he had succeeded in growing the Treponema
pallida in vitreo, and, a few months later, he published his
first article on the luetin test in the same journal. This test
for syphilis is analogous to the intra-dermal tuberculin test of
Mantoux and Moussu, and the technique is the same. Luetin
consists of a sterile emulsion made from cultures of the

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Treponema pallida , and to obtain it the organism is grown on
ascitic fluid agar for from six to fifty days under anaerobic
conditions. The growths are then ground down in a mortar,
and an emulsion is made by adding cultures of treponema in
ascitic fluid. This emulsion, when sterilised, is ready for use.
A dose of 0 07 c.c. is diluted with an equal amount of normal
saline, and injected intra-dermally with a fine needle, and the
local reaction observed.

When the reaction is negative, a small wheal appears in a
few hours, and in twenty-four there is some induration, and a
faint hyperaemic blush at the site of injection. This hyperaemia
fades rapidly in a day or two, but the induration, which is
usually about 3 mm. in diameter, may still be felt four or five
days later as a minute nodule in the skin.

Three types of positive reaction have been described. First,
an indurated papule surrounded by more or less erythema, and
usually quite tender, appears in twenty-four hours, and tends to
increase to the third or fourth day, when it may regress ; or it
may pass into the second or pustular type of reaction, in
which a small pustule forms at the site of injection, and after
a few days becomes absorbed, leaving an indurated area which
may persist for a considerable time. The pustule is usually
small and remains dry, requiring no particular attention. None
of our cases in which pustulation took place required any
local dressing whatever. In some cases, however, much more
marked local reactions have been reported. Wolfsohn, in his
first series of cases, records two who complained of painful and
tender arms, and one of these had enlargement of the axillary
glands. He also mentions several cases in which haemorrhagic
pustules appeared, which were opened and exuded semi-fluid,
grumous material. Benedek also records three cases in which
on the fifth day the areola measured 3 to 5 cm. in diameter,
and in which the pustules discharged a thick, brownish-yellow
fluid on the eighth to the tenth days, after which involution
began. A papule could be distinctly felt three weeks later,
and the skin was discoloured.

The third type of reaction has been termed the torpid form.
In it the reaction is delayed for anything from four to twenty-
eight days after injection, and, when it does appear, usually
takes the pustular form. This torpid form is most commonly
seen in parasyphilitic and congenital cases, and was present in

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two of our cases, one a general paralytic in a state of remission
which had lasted two years, and the other a boy of nine
suffering from congenital general paralysis. VVolfsohn, out of
12 cases with cardio-vascular lesions, obtained a torpid reaction
in six.

Constitutional disturbances are not common. None of our
cases manifested any. Cohen reports 179 cases tested with
no bad effects, while Boardman and Gorham record 52 with no
constitutional disturbances, and Kilgore saw none in 120.
When present the symptoms consist of malaise, tachycardia,
abdominal pains, bone pains, slight nausea, and occasionally a
little fever. These usually last only twenty-four to forty-eight
hours. Wolfsohn records one case, a tabetic, who after injection
had a fever of 103°, with severe abdominal pains and vomiting
resembling crises.

Some doubts have been thrown on the value of the test in
view of the fact that a similar reaction has been obtained with
other substances than luetin. For example, if the luetin
emulsion be injected into one arm, and a control emulsion
made from the uninoculated culture media into the other, a
reaction of almost equal intensity may appear in both arms.
This is due to a special sensitiveness to trauma of the skin of
syphilitic persons in the later stages of the disease, and has
been termed by Neisser “ Umstimmung.” It is in itself
characteristic of syphilis, but is a very inconstant phenomenon,
and has little bearing on the luetin reaction.

Most observers are agreed that the test is of little value in
primary and secondary untreated syphilis. If the test be
looked on as an anaphylactic phenomenon, indicative of a state
of hypersensitiveness to the specific proteins of the spirochaetes,
which state is induced by a period of cessation of the intro¬
duction of these specific proteins, then its failure in the primary
and untreated secondary phases of the disease is easily under¬
stood. The disease is then so active that the patient cannot
acquire the anaphylactic state necessary for the reaction. This
also explains the fact that cases which, previous to treatment,
gave a negative reaction, after treatment may give a positive
one, and in this way the test may be used as a gauge for the
efficacy of treatment. In tertiary, congenital, latent, and
parasyphilitic cases the hypersensitiveness to the proteins of
the spirochaete necessary to give a positive luetin reaction is to

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be expected, and it is in these cases that the test should prove
of value, and this expectation has been confirmed by the clinical
findings.

We were able to carry out the test in sixteen cases and to
contrast it in each case with the Wassermann reaction. Out
of these cases, twelve were general paralytics, and two cases of
cerebro-spinal syphilis. Of the remaining two cases, one was
a man who stated that he had contracted syphilis thirty-six
years previously, and had received little or no treatment. In
his case, both the luetin and Wassermann tests were quite
negative, and, on further questioning him in the light of these
results, we considered it most probable that his venereal infec¬
tion was not syphilitic. The remaining case was one of some
interest ; the patient had suffered for some years from maniacal
excitement, and the character of his mental symptoms, the
absence of knee-jerks, and the presence of unequal and sluggish
pupils, along with the development of early optic atrophy, had
suggested the possibility of general paralysis and syphilitic
infection. The Wassermann test first proved negative in the
blood serum, but on applying the luetin test a markedly
positive reaction was obtained. This led us to apply the
Wassermann test to the serum and cerebro-spinal fluid once
again, and, on this occasion, we found the reaction still negative
in the serum, but faintly positive in the spinal fluid, five doses
of complement being deviated. In this case, the luetin proved
of very considerable assistance in confirming the diagnosis.

Cases of General Paralysis.

Of the series of cases of general paralysis, 9, or 75 per cent.,
gave a positive luetin reaction. On making a table of these
results, and comparing them with those of the Wassermann
reaction, one finds that the positive cases may be divided into
two groups—those giving the papular or slight type of reaction,
and those giving the pustular or marked type. In the first
group there are four cases, and in the second five. If the degree
of the luetin reaction be compared with strength of the
Wassermann reaction, that is, with the number of doses of
complement deviated, an interesting co-ordination is brought
out. In the cases giving a “ slight ” luetin reaction, the extent
of deviation of complement was also slight, ten doses or under,

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while in the cases giving a marked reaction the extent of
deviation of complement was also marked, ten doses or over.

Positive Cases of General Paralysis .

Wassermann.*

Case.

•

Luetin.

slight

Blood Serum.

. O

c.s.f!

•

. 10

•

„ (torpid)

• 5

•

marked

. 12

•

. 12

•

„ (torpid)

•

. 10

I am not aware that there is any series of cases in which any
connection between the degree of the two tests has been noted,
and it is, of course, not permissible to draw any conclusion from
such a short series of cases as this. As the positive Wassermann
is indicative of the presence of metabolic substances produced
by present or recent activity of the spirochsete, while the luetin
is indicative of a state of hypersensitiveness to the specific
proteins, there is no very apparent reason why there should be
any correlation between the degrees of the two reactions. A
more extended series of observations on this point would be
of considerable interest.

Negative Cases of General Paralysis.

Wassermann.

_ —_

Case. Luetin. Serum.

1 . Negative . 30

2 . „ . 15

3 • n • 7

C.S.F.

In the first two negative cases, it will be seen that the
Wassermann reaction was strong, and in both the disease was
progressing steadily, and the physical symptoms particularly
were marked. In the third case, the patient had been in a state

* The figures in this column indicate the number of doses of complement
deviated.

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of acute excitement for a year, but had very few physical signs
of the disease. The Wassermann reaction in his case was slight,
and he was exactly the type of case in which a positive luetin
might have been expected, and would have been of diagnostic
help. The further progress of this case, however, has been such
as to render the diagnosis of general paralysis very doubtful,
and a Wassermann reaction recently performed proved entirely
negative. The percentage of positive reactions in this series
of cases coincides fairly well with that of Benedek, who in a
much larger series (81 cases) of general paralytics obtained a
positive luetin in 8o’4 per cent.

Cases of Cerebro-spinal Syphilis.

The test was applied to two cases of cerebro-spinal syphilis,
and was positive in both. In both, the reaction was a well-
marked one, and this is of some interest, as Benedek noted, in
the three cases which he tested, a reaction which was so well
marked in comparison to those which he obtained in his cases
of general paralysis as to lead him to suggest that the type of
reaction might be of aid in distinguishing the two conditions :

Wassermann.

, - * - .

Case. Luetin. Serum. C.S.F.

1 . Marked . 2 . i

2 „ . Partial . Partial.

Both these cases gave very slight deviation of complement
with alcoholic extract, but with lecethin and cholesterin were
definitely positive. Both had been under treatment by potas¬
sium iodide and mercury with very beneficial results, as the
number of cells in the cerebro-spinal fluid had fallen in a period
of sixteen months from, in the first case 555 to 4 perc.mm., and
the second from 520 to 7’3 per c.mm.

If the case with optic atrophy, which has already been
described, be included in the series, we found that out of fifteen
cases of parasyphilis, twelve gave a positive luetin reaction,
that is, 80 per cent. This figure agrees well with the average
results of other observers. If the series of parasyphilitic cases
recorded by Kilgore, Wolfsohn, Benedek, and Boardman be
added together, it is found that, out of a total of 121 cases,
95, or 78'5 per cent., gave a positive luetin reaction.

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INJECTION OK SALVARSANISED SERUM,

[April,

The results obtained with the Wassermann reaction especially
in general paralysis are more constant. Dr. Robertson, in his
Morrison Lectures for 1913, states that the reaction in general
paralysis is positive in 99 per cent of cases in the blood serum,
and in 94 percent, in the cerebro-spinal fluid.

In conclusion, the luetin reaction is a valuable addition to
our diagnostic tests for syphilis. It is easily carried out by
the clinician, is absolutely specific for the disease, and is occasion¬
ally positive in cases in which the Wassermann is negative.
In comparing the value of the two tests, Much states that when
it is a question of ascertaining if the patient has ever been
infected with syphilis, the luetin is the more instructive, but
when it is desired to know if the disease is still active, the
Wassermann is the more helpful. These facts warrant its
receiving much more attention than has hitherto been the case
in this country.

References.

Noguchi.— Journ. Exper. Med., No. 6, 1911.

Wolfsohn.— John Hopkins Hasp. Bull., August, 1912.
Benedek.— Munch. Med. Woch., September, 19x3.

Cohen.— Arch, of Ophthalmology, January, 1912.

Boardman and Gorham.— Boston City Hasp. Reports, 1913.
Kilgore.— Journ, Amer. Med. Assoc., April, 1914.
Robertson.— Morrison Lectures, 1913.

Much.— Med. Klinik., Beilin, May, 1914.

Brit. Med. Journ., May, 1914.

Foster.— Amer. Journ. of Med. Sci., November, 1913.

Remarks on the Intracranial Injection of Salvarsanised
Serum. By G. H. Monrad-Krohn, M.B., M.R.C.P.Lond.,
M.R.C.S.Eng., Assistant Medical Officer, London County
Asylum, Bexley, Kent.

In the Lancet , July 4th, 1914, I have briefly described the
method of what I called “ subdural injection.”

In a very interesting article in the Journal of Mental Science,
October, 1914, by Mapother and Beaton, dealing with the
intrathecal treatment of general paralysis, the authors criticise
the different methods of intracranial injection. As regards the
subdural injection, they state that it appears “ to have no

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BY G. H. MONRAD-KROHN, M.B.

251

rational basis whatever, for there is no anatomical communica¬
tion between subdural and subarachnoid spaces, nor is there
any evidence that absorption occurs from the former to the latter.”

I do not feel absolutely convinced that there is no communi¬
cation between the subdural and subarachnoid spaces, and, in
my opinion, there is reason to believe that absorption may
occur from the subdural to the subarachnoid space. Golla’s
experiments—as related to me at least—show that an absorption
of colloidal carbon can take place from the subdural to the sub¬
arachnoid space; and if colloidal carbon can pass the arachnoid
membrane, there seems to be reason to believe that salvarsanised
serum can also do so. However, it must clearly be pointed
out that our knowledge about the permeability of the different
membranes of the brain, and also of the circulation of the
cerebro-spinal fluid, is still insufficient to allow any definite
conclusion as to the utility or otherwise of subdural injections.

Practically there is, however, hardly any reason to distinguish
between subdural and subarachnoid injection. The subdural
space is only a potential space, and once the needle has
penetrated the dura mater it has not far to go before it penetrates
the arachnoid. In my first injections I made a point of per¬
forating the arachnoid by pushing the needle a little farther in,
and then withdrawing it again before injecting, and in my first
short publication (*) I also called the injection a “ subarachnoid ”
injection. As a matter of fact, it is partly a subdural and partly
a subarachnoid injection.

I shall briefly describe what one finds by opening the cranium
immediately after an injection, post mortem , of stained fluid.
Although an injection, post mortem , cannot give us any idea of
absorption or permeability of the membrane, it will decide the
question of the immediate fate of the injected fluid. I used
weak eosin and methylene blue solutions (20—30 c.c.) and
injected it after the method described in the Lancet , July 4th,
1914. The skull was opened immediately, and the injected
fluid was found partly in the subdural space, and partly in the
subarachnoid. That the stain actually reached the subarachnoid
spaces was proved by the following facts: (1) It could not be
washed off, (2) the arachnoid membrane was bulging over the
subarachnoid spaces, (3) the staining fluid could be moved
under the arachnoid by stroking with the finger; thus, it could
not have been staining only of the arachnoid.

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As to the distribution of the injected fluid which entered the
subarachnoid space, it was not only confined to the frontal area
—the site of the injection—but had also spread to the wider
parts of the brain, particularly to the base, and also along the
Sylvian fissure on the other side, and from there along the
perivascular spaces over the convexity of the hemisphere opposite
to the side injected.

It seems, therefore, that, by injecting fluid in the way I have
described, a considerable part of it immediately reaches the
subarachnoid space, and consequently not wholly by absorption
through the arachnoid.( 2 )

Whether the subarachnoid space is a closed one, as Turnbull
and Fildes believe it to be, or not has yet to be decided by
further investigation, also as regards the permeability of the
pia. Nearly every point in the physiology of the cerebro-spinal
fluid will need to be closely studied in order to give a more definite
basis for intracranial injections. In the present state of know¬
ledge, however, the only clinical way in which we can approach
the question of the utility of the various methods of intracranial
injection is by comparing large groups of cases, ( a ) which have
not received any treatment at all, ( b ) which have been treated
with intravenous salvarsan injection only, and (c) which in
addition have had administered intracranial injection. Because
of the irregular course which individual cases of dementia
paralytica take, it is most important that groups comprising
large numbers of cases should be compared, preferably at the
same stage (as far as can be judged clinically), and under the
same conditions.

It does not seem superfluous to point out that the subjective
feeling of patients is of no importance in judging the results, as
feeling of elation is often a symptom of dementia paralytica.

Only a minute mental and physical examination is of value
in deciding whether any improvement or not has taken place.

Furthermore, too great expectations of the salvarsanised
serum treatment must be avoided. Even if the spirochaetes in
the brain are killed, additional neurons cannot be created in the
place of those already destroyed. What we may expect of
this treatment is mainly an arrest of the further development
of the disease, an expectation which will require some years’
experience to justify. The result of a few cases observed only
for some months (the judgment, in addition, often being in-

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253

fluenced by the patients’ repeated statements of perfect well¬
being) is of less than no value, and can only give rise to false
expectations.

After the above had been written I made some injections,
post mortem , of 40 c.c. of water by the same intracranial
method, after which I noticed the subarachnoid spaces all over
both hemispheres bulging and filled with a clear fluid.

I have also tried the following method :

(1) Intracranial injection in the usual way of 5 c.c. of 20
per cent, sodium nitroprusside solution, mixed with 5 c.c. 2 per
cent, phenylhydrazin solution and 20 c.c. ox serum. (This fluid
physically resembles the salvarsanised serum very much.)

(2) Immediate opening of the skull; and

(3) Washing the brain in water for a few seconds, and then
placing it in a 4 per cent, solution of formaldehyde, which is
made slightly alkaline by means of KOH.

By this method a blue colour obtains where the formaldehyde
and injected fluid meet.

All these injections of various fluids intracranially show the
same result—that by the method I have described the injection
is subarachnoid as well as subdural—and that the part of the
brain which the injected fluid first reaches is the left frontal
lobe, which is decidedly an advantage.

I am of the opinion that the method of intracranial injection
I described in the Lancet, July 4th, 1914, is one which combines
the greatest simplicity with the greatest prospect of efficacy.
The method is as follows: The skull, about 10-12 cm. above
the anterior end of the left zygomatic arch, is trephined with a
J in. trephine. The dura is punctured obliquely in a forward
direction with a fine needle, which is pushed in about 2—3 cm.
and then withdrawn, so that about 1 —1 -Jem. of the needle is
inside the dura. The salvarsanised serum is injected quite
slowly. Any irregularity, and especially slowing down, of the
pulse rate is an indication to stop the injection. (As a rule,
25—30 c.c. can be injected without any inconvenience).

It can all be done under local anaesthesia, 6 c.c. of 1 percent.
novocain solution being sufficient, as only a very small flap is
needed for the trephining. The cutaneous incision may be
made behind the border of the hair; but care must be taken
not to trephine too far to the back, as haemorrhage from one of
the branches of the middle meningeal artery may then be a

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rather tiresome complication. The trephine opening itself
should not be behind the frontal plane through the anterior
end of the zygomatic arch. A safe distance must be kept
from the superior longitudinal sinus in the middle line. The
skull itself is insensitive. I have found it an advantage to give
£ gr. morphia hypodermically about half an hour before the
operation. The wound is sutured whilst the patient is sitting
up ; the trephine aperture in the skull is left open for sub¬
sequent injections. These are performed by puncturing
through the skin, pushing the needle in slowly till the cerebro¬
spinal fluid trickles out (the patient lying with his head low);
then the patient is raised to the sitting position, and the in¬
jection is carried out.

I have to thank Dr. T. E. K. Stansfield for permission to use
the post-mortem material, and Dr. E. Faulks for valuable advice
during my work.

(') Norsk Mogaein for Lesgevidtnskaben , Christiania, 1914, No. 5.—(*) I may
add that for injections post mortem I have preferably selected cases of dementia
paralytica, in order to obviate the objection that the adhesions in this disease might
possibly prevent the access of the fluid to the different parts of the subarachnoid
space.

Clinical Notes and Cases.

Notes on Juven He General Paralysis , with the Clinical
Description of a Case. By C. H. G. Gostwyck,
M.B.Edin., F.R.C.P.E., Senior Assistant Physician,
Stirling District Asylum, Larbert.

Juvenile general paralysis is of interest as illustrating one
of the many ways in which syphilis may produce its detrimental
effect on the human race. The disease may commence at a
very early age; according to Thomson, progressive symptoms
may be evident in children as young as three years. Males and
females are victims in practically equal proportions. The
symptoms are very similar to those of the adult form, progres¬
sive dementia being very marked; such variations as are
present are due to the more undeveloped mental state of youth,
and on the whole it corresponds to the demented or confused
type of the adult. Periods of acute excitement, or of mental

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became dirty and required attention as would an infant. During this
later period his parents observed that his legs were becoming stiff, and
he walked very badly. Eventually he was confined to bed owing to
muscular weakness. There was no history of fits or convulsions.

When admitted to Stirling District Asylum on October 7th, 1913,
his general condition was very poor. He was quite unable to walk, and
could not stand without assistance. His legs were spastic, and move¬
ments of hands and fingers inco-ordinate. His speech was indistinct
and inarticulate, the sounds he uttered were unintelligible, the only
word which could even be guessed at being “mother.” Sphincter
control was quite lost, fasces and urine being voided involuntarily.
Sensation, as tested with a pin prick, was markedly diminished all over.
The knee-jerks were much exaggerated, and the plantar reflexes normal.
His pupils were equal, much dilated, but reacted sluggishly to light.
He gave no sign that sounds were audible, and did not seem to under¬
stand what he saw. His teeth were typically of Hutchinson type,
notched and peg-shaped, and there were old syphilitic scars around the
angles of his mouth. His heart’s action was irregular, but there was no
alteration in the character of the sounds. Pulse, 120. Temperature,
100*2° F. His mental condition was one of dementia, with some
temporary agitation at first which passed off within an hour or two after
admission. He was quite unable to understand what was said to him,
or to give any indication as to his condition, nor could he look after
himself in any way. He required to be fed and tended after the fashion
of a general paralytic patient in the third stage. One month after
admission his sphincter control had improved, but he was as helpless as
ever. His expression was one of quiet imbecile pleasure. He smiled
when spoken to, and to everything responded with a word that sounded
like “ fine.” Occasionally he was mildly restless, turning about in bed,
but never attempting to get up. Lumbar puncture gave a result
positive for general paralysis ; the pressure was increased, the fluid clear
and alkaline, markedly turbid on boiling, and the Nissl-Nonne test was
positive and well marked ; the cells were greatly increased, averaging
twenty per field, lymphocytes plentiful with plasma cells, some Gitter
cells, and a few polymorphonuclear leucocytes. During the following
months his condition grew slowly worse, until, at the beginning of the
fifth month of his residence, he was very thin and emaciated; he made
no sound, his only movement was to turn his head from side to side,
and his legs and arms had become very contracted. He died six months
after admission, a pulmonary congestion setting in two days prior to
his death. There were no convulsions or seizures during the course of
his illness.

The post-mortem appearance of the brain was typical of general para¬
lysis—the dura was thickened, no pachymeningitis haemorrhagica was
present. The arachnoid was thickened and opalescent, especially along
the line of the vessels, and adherent to the tips of the convolutions,
causing small erosions when stripped off. The convolutions were
wasted, and separated from each other, especially on the anterior half of
the cerebrum. The lateral ventricles were much enlarged, and thickly
covered with granulations, as was the floor of the fourth ventricle.
There was excess of cerebro-spinal fluid, and the blood-vessels at the

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base of the brain were thickened. The brain weighed 43 oz. The
microscopic appearances confirmed the diagnosis, as the characteristic
group of lesions were very definite. The vessels showed marked peri¬
arteritis with plasma-cells, there was much proliferation of neuroglia,
and the nerve-cells were degenerated. The central canal of the spinal
cord was entirely closed throughout its whole length by proliferated
endothelial cells.

Whilst this lad was a patient, his mother, ret. 40, was admitted suffer¬
ing from acute melancholia, and died after the attack had lasted three
months. Unfortunately, no post-mortem was permitted, but her
symptoms did not suggest general paralysis.

In this case, a congenital syphilitic, mentally deficient boy,
the onset appeared at the age of fifteen in a slow but definite
progressive mental deterioration, followed by a more rapid
mental change after a scolding, which may have provided an
accessory factor of mental stress. The neuronic degeneration
seems to have been somewhat swift, as it was well marked
within two months after its commencement. The emotional
state changed quickly, for he passed through a phase which
had a melancholic colouring within the same period; and
appearing later was a condition of euphoria, as judged by his
expression of happiness, and the inane smile he assumed when
addressed. He exhibited no delusions or hallucinations at any
time, and no seizures or “ faint turns ” were noticed prior to
admission, and certainly none after. The duration of the
disease from onset to death was only eight months.

It was thirty-seven years ago, when general paralysis of the
insane was believed to be a disease confined to adult life, that
Sir Thomas Clouston recorded the first case of juvenile general
paralysis in a boy, set. 16, and since then many other cases
have been recognised, until it is no longer considered to be so
very uncommon. Fennell looks on the disease as one which is
by no means the rarest form of breakdown in children, and
places the number among imbecile children at 5 per cent.; and
Dr. Clarkson tells me that there are nearly always one or two
among his patients at the Institution for Imbecile Children at
Larbert.

The cause of general paralysis in the adult is now recognised
to be syphilis, and has been proved by the researches of Noguchi
and others, by the finding of the Spirochcela pallida in the
brains of those dying from the disease, and we have the same
factor acting as a congenital infection, and causing the same

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paretic symptoms in young persons. Syphilis is also a factor
in the causation of imbecility, but there is a considerable dis¬
crepancy between the percentages obtained by various observers.
Tredgold quotes the results of eight observers in different
countries, of which three find positive Wassermann reactions
which vary from 1*5 per cent, to 4'8 per cent., and five give
positive reactions varying from 15 per cent, to 30 per cent.
Chislett obtained a positive reaction in eight of fourteen cases
of imbecility.

Fraser and Watson placed the percentage at the high figure
of over 50 per cent, of the mentally defective children they
examined, and only a very small percentage of their cases
giving a positive Wassermann reaction showed external evi¬
dence of congenital syphilis.

It is impossible in early life to say whether any given imbecile
child will prove later to be a general paralytic, and only after
the progressive symptoms have shown themselves can the case
be declared as one of dementia paralytica. A systematic per¬
formance of lumbar puncture of young imbeciles, especially
when combined with the Wassermann test, might prove to be
of interest and productive of valuable results from the point of
prognosis, at the same time throwing some more light on the
incidence of progressive paralysis among such patients. By
no means every child which is the subject of congenital syphilis
develops into a general paralytic, and this seems to lend some
colour to the idea that there may be some special form of
spirochaete which causes the symptoms of general paralysis,
especially when we consider those cases in which husband and
wife have both suffered from the disease, the one having infected
the other, and where one person has infected several others,
who, later on, develop general paralysis, and also the more
unusual cases where both parents and child have all been
general paralytics. Although this form of spirochaete has not
yet been isolated, there are some grounds, in the slowly
accumulating evidence, for belief in its existence, and possibly
the present view that in general paralysis the central nervous
system is especially vulnerable to the toxic effects of the
Spirochcete pallida, or that this organism is assisted by the
Bacillus paralyticans, will require to be modified.

Bolton has put forward an interesting theory with sup¬
porting evidence with regard to general paralysis. He holds

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that subjects of this form of mental disease would, had they
not been syphilised, have suffered from one or other types of
primarily neuronic dementia, and he is of the opinion that an
attack of syphilis is a necessary antecedent to dementia para¬
lytica, supporting his argument by the appearances presented by
the brains of general paralytics and those of progressive senile
dementia, which do not differ in their essential pathological
features. With regard to juvenile general paralytics he ex¬
presses the opinion that had these children not been syphilitic
they would have become ordinary examples of stationary pre¬
mature dementia. But, in consequence of this infection, paretic
symptoms show themselves at a time when the neuronic
activity is becoming most evident, and this activity replaces
the ordinary stress and strain of adults, with the result that
degeneration of the neuronic elements follows as a natural
sequence. This last view has something to recommend it when
we consider that there can be no stress of life affecting those
imbeciles who develop general paralysis; and in those young
persons who are not, or are only mildly, mentally defective the
stresses of life can only affect them to a slight degree, for their
age is often somewhat young to expect them to react to these
in a manner which can compare with the more developed
brain of an adult, and the other usual factors, such as alcohol
and sexual excess, can be excluded.

The treatment of juvenile general paralysis must be on the
general lines as for the adult form, and, although the benefit of
salvarsan is still undecided yet, there are sufficient instances of
amelioration on record to justify its use even in those who have
been imbecile from birth ; and more especially in those cases
which are seen during the earlier stages. The treatment
devised by Dr. G. M. Robertson of intra-venous injection
of salvarsan, together with intra-spinal injection of antisyphi¬
litic serum, combined with the administration of urotropine
and calomel, gave definite evidence of a promise of satisfac¬
tory results, three out of twelve cases so treated recovering
sufficiently to be discharged from institution care. And he
was inclined to believe that the negative results were due to a
want of vigour in pushing remedies in a combination and
system which was at the time tentative.

In support of the fact that salvarsan undoubtedly does good
in actual imbecility arising from syphilis, Finlay has published

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some very striking results, and leaves the impression that the
same remedy might be administered in most cases of imbecility
with advantage. And perhaps a similar amelioration might be
expected in those cases of imbecility which, on showing some
progressive mental and physical symptoms, might well prove
themselves to be cases of juvenile general paralysis.

References.

Abraham.— Lancet , 1910.

Bolton .—Brain in Health and Disease.

Chislett.— Journ. Merit. Sci., July, 1911.

Clouston .—Neuroses of Development.

Diefendorf. — Clinical Psychiatry.

Fennell.— Practitioner, 1907.

Finlay .—Glasgow Medical Journal , October, 1914.

Fraser and Watson.— Journ. Merit. Sci., October, 1913.

Mott .—Archives of Neurology, vol. i.

Mott.— Ibid., vol. vi.

Robertson .—Morrison Lectures, 1913.

Thomson .—Treatment of Sick Children.

Tredgold .—Mental Deficiency.

Watson .—Archives of Neurology, vol. ii.

The Clinical Simulation of General Paralysis of the
Insane. By J. R. Perdrau, M.B., B.S.Lond., Assistant
Medical Officer and Pathologist, Dorset County Asylum.

It happens not unfrequently that a provisional diagnosis of
general paralysis is made in the insane, which the subsequent
course of the case fails to confirm. In the three cases on which
this paper is based a diagnosis of general paralysis was made, in
one of them quite confidently, and in the two others only as a
last resort, because the course of the disease presented so many
unusual clinical features. These three cases are specially
interesting because a post-mortem examination was made on
each of them, and so permitted of a confirmation or otherwise
of the diagnosis, and also on account of the very’’ interesting
pathological findings.

A. B—, female, set. 62, admitted November, 1911, died May, 1912;
duration on admission said to be one week only. On admission she
was very dull and confused, had a weak, unsteady gait, and general
tremors ; knee-jerks were dull but equal; pupils equal, and reacted both
to light and accommodation ; pulse 76. When I saw her on February'
15th, 1912, she was weak, very unsteady on her legs, tremors of tongue

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were very marked, speech very slow, deliberate, and slurred, knee-jerks
dull but equal, pupils equal and reacted both to light and accommoda¬
tion, pulse 64. She was unable to attend to her bodily wants. Mental
condition too dull for intelligible answers to be given.

A fortnight later she had what was described to me as a typical con¬
gestive seizure, and on the following day the head and eyes were still
turned towards the left. I then considered the possibility of a cerebral
haemorrhage, but the signs cleared up too quickly. I attached no im¬
portance to the short history given on admission, and looked upon her
as probably a case of general paralysis. I did not see her again after
the month of March, and she died in May, becoming gradually more
feeble, and being finally unconscious for twenty-fours before death.

I was not present at the post mortem , where a tumour of the
size of a Tangerine was found pressing on the left frontal region,
and hanging by a small stalk from the pia in the neighbourhood
of the optic chiasma. When I look back upon the case it is
clear that certain features, to which I did not then attach
sufficient importance, do not seem to agree with a diagnosis of
general paralysis ; for instance, she was always dull and drowsy,
with a pulse of about 60, the deep reflexes were only a little
blunted all round, but quite normal otherwise ; and also her
sex and age were against general paralysis of the insane. On
the other hand, it must be remembered that there were no
localising signs, such as paralysis and alteration of the deep
reflexes, and there was no vomiting. Her very unsteady gait
was probably due to vertigo, of which she could not complain.
She had never complained of headache in the first part of her
illness, and, as cerebral compression was not suspected, the
fundus of the eyes was not examined, and such an examination
is never an easy performance in a lunatic.

The tumour itself was very interesting. It was the size of a
Tangerine and was made up of a collection of cysts as big as
marbles, with translucent walls and each containing a clear, thick,
colourless fluid like the white of an egg. In the walls of the loculi
was a variable amount of denser tissue containing small masses
of a cream-coloured, opaque substance, which looked like caseous
material to the naked eye. Microscopically, the walls of the
cysts are made up of layers of polygonal cells, which are from
two to twenty deep. These cells resemble those of the Mal¬
pighian layer of the skin, and as they approach the lumen of
the cyst tend to assume a more and more cylindrical character
until the lining cells of the lumen are definitely columnar in

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type, but lack a basement membrane. In a few rare places
these cells are elongated, and form definite whorls arranged
round some similar cells in their centre. The cysts themselves
contain some colloid material, which has solidified in places, and
there is undergoing organisation. The gritty, caseous-looking
particles are whorls of large granular cells, whose nuclei are
mostly represented by an empty space, and which stain a
bright yellow with Van Gieson’s stain. These whorls are of
all sizes, and in only one instance was a blood-vessel seen
running through its centre. Although the two kinds of tissue
exist side by side, no obvious transition can be seen of the
cells of one kind of whorl passing into those of the other.

B. C—, female, ast. 49, admitted 1908, died 1912. History was
defective, but she had been looked upon as eccentric for the last twenty
years. On admission she was confused and emotional, had an impaired
memory, and an exaggerated sense of well-being. She showed most of
the physical signs of general paralysis— e.g. knee-jerks exaggerated and
unequal; pupils also unequal, and reacting very poorly to light; tongue
tremulous, speech slurred, etc. In addition to restlessness, she showed
a tendency towards choreiform movements, especially as regards the
head and arms. Her subsequent history is one of gradual mental and
physical deterioration, and she was soon quite demented.

We always looked upon her as a case of general paralysis,
and it was not until towards the end of her illness that the
slight choreiform movements, which still persisted in the head
and arms, impressed me as being of diagnostic significance on
account of their stereotyped character, and the probability was
only then recognised of her being rather a case of chronic
chorea, if not actually of Huntington’s chorea.

At the post mortem nothing was found with the naked eye,
or later microscopically, to confirm the earlier diagnosis of general
paralysis, the morbid appearances being only those of an ordinary
case of chronic insanity.

An attempt was made to elucidate her family history, but no
evidence of chorea or insanity in her family was obtained, the
information gathered being very unsatisfactory.

C. D—, female, aet. 40, admitted April, 1911, died in September, 1911.
She had a previous attack six years previously. Her only child was born
three and a half years before, and since then she had undergone three
uterine operations, apparently curettings.

On admission she was excited, showed marked delusions of grandeur,
and was very emotional. She was very anaemic ; gait unsteady; speech

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JOURNAL OK MENTAL SCIENCE, APRIL, 19.5.

Fig. 1 (Case 1).—Main tissue of tumour
giving rise to whorls and to a columnar
pseudo-epithelium. Note tendency to
cyst-formation beneath latter. Magni¬
fied } in. x No. 4 oc.

Fig. 3 (Case 1).—Part of large whorls.
Magnified same as Figs. 1 and 2.

To illustrate Dr. J.

Fig. 2 (Case 1).—Both kinds of tissue
shown side by side. Nuclei of large
cells practically non-existent. Magni¬
fied same as Fig. 1.

Fig. 4 (Case 3).—Organisms in brain,
mostly in pairs, x 750.

. Perdrau's paper.

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Atilaril Sun, lmfr.

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slow and deliberate ; deep reflexes much exaggerated ; reaction of pupils
to light normal; general tremors fairly well marked, especially of lips ;
calf muscles tender to pressure, etc. In view of these signs, the possi¬
bility of her being a case of general paralysis was not lost sight of from
then onwards. She was a little quieter at first, but not for long, and
later became very emotional, and was very depressed at times. She
became gradually weaker and more ataxic, complained of pain in the
back, and required some help to walk. Towards the middle of August,
from being intensely exalted and emotional, she became quickly stupo-
rose, and had to be kept in bed. She lost control over her sphincters,
sensation became much blunted, blebs formed on the heels, and she
developed diarrhoea with pyrexia. Both the latter — 1. e. the diarrhoea
and the fever—increased and were present until death.

There was nothing to suggest dysentery or any ordinary fever.
Typhoid was excluded clinically, and by the Widal reaction ; a blood-
count, total and differential, showed an increase in the eosinophiles
only. She developed great difficulty in swallowing towards the last,
death resulting from complete exhaustion in September, some hyper¬
pyrexia being present towards the end.

We were allowed to make a post-mortem examination of the
brain only. No signs of general paralysis were found with the
naked eye nor subsequently by the microscope. Membranes were
quite normal, not even congested ; cerebro-spinal fluid normal.
The only unusual feature was several small pink areas on the
surface of the cortex of the cerebral hemispheres, especially
over the vertex. Although the post mortem was held well over
twenty-four hours after death, the brain was well preserved.
Pieces of the brain were fixed in the usual way. The most
obvious microscopic appearance was complete chromatolysis,
together with the presence of a large bacillus scattered generally
through the brain-matter, both grey and white. As it was too
late for attempting a culture of the organism, its identification
became impossible. It was, however, Gram-negative and non-
acid-fast, stained evenly, possessed slightly rounded ends, and
was seen to be often in pairs.

We were then no nearer a solution of the nature of the disease
she had suffered from, and there matters remained until some
eighteen months later, when cases of pellagra were reported
from various asylums in this country. One feature in the
appearance of the patient, which we had thought too trivial to
mention in the case-book, was then recalled. She had shown
an extreme condition of “ sunburn ” of the backs of both hands
and also of the face, especially of the forehead. It was all the

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more remarkable as she was admitted in early spring, and
although she did not go out of doors much in the latter part
of her illness, the condition progressed, and towards the end
the skin of the back of the wrists was beginning to crack. The
“ sunburns,” the time of onset— i. e. early spring—the peculiar
mental and nervous signs, and the terminal diarrhoea are, to say
the least, very suggestive. As regards the micro-organisms, I
should not like to say more than merely record their presence
some twenty-four hours after death, as the possibility, if not
probability, of a post-mortem dissemination must be remembered.
Besides, if the organism was at all connected with pellagra, it
would be very extraordinary indeed if it had not been observed
before, as it stains easily with aniline dyes, and is visible even
with the low power of the microscope. On the other hand, the
pink areas on the surface of the brain seem to point to a vital
reaction, viz. an encephalitis, although these areas could only
be recognised with difficulty under the microscope by their
congested vessels. The terminal hyperpyrexia and complete
chromatolysis also seem to point to the same conclusion.

In these three cases, who all died in 1912, a negative
Wassermann reaction would undoubtedly have set one on the
track of some other disease, but opportunities for this and other
serological examinations were not then available.

That the three diseases here considered do resemble general
paralysis has long been known, and frequent reference to that
fact is found in medical literature. Mott(i) says that pressure
of a tumour, usually an endothelioma, on the left frontal region
of the brain may produce a condition resembling general para¬
lysis. He also mentions the fact that such tumours may show
close resemblance to a carcinoma, owing to their alveolar
character.

It is especially in Huntington’s chorea that a resemblance
is most marked, and in asylums it is not uncommon to find in
such cases that a diagnosis of general paralysis had been made
on admission some twenty to thirty years before ; whilst some
writers have even gone so far as to suggest that Huntington’s
chorea is a hereditary form of general paralysis.

In the second case under review a history of hereditary pre¬
disposition was not obtained, and it would seem as if Hunting¬
ton’s chorea cannot be differentiated clinically from isolated
cases of mild chorea with stereotyped movements and insanity.

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There is now in the Dorset Asylum an old woman, who
shows marked stereotyped movements, who, on admission at
the age of thirty-eight in 1873, suffered from a recent right¬
sided hemiplegia, which only began to clear up some ten years
later, when she was found to show all the typical signs of
general paralysis, and was then looked upon as a case of that
disease. Choreiform movements, chiefly of head and arms,
began to appear then and have persisted ever since. In her
case, too, no evidence of hereditary chorea can be obtained.

Osier (2) thinks that these isolated cases of chronic adult
chorea are indistinguishable from Huntington’s chorea, and
should be classed with the latter.

In cases of pellagra, too, its occasional close resemblance to
general paralysis has been often referred to. Tanzi (3) describes
special forms of that disease under the names of pseudo¬
progressive paralysis, pseudo-tabes, etc. It is interesting that
he refers to the terminal diarrhoea as a pseudo-typhoid.

References.

(1) General Pathology , edited by Pembrey and Ritchie, p. 406.

(2) Principles and Practice of Medicine.

(3) Text book of Insanity.

Occasional Notes.

The Sixty-eighth Report of the Commissioners in Lunacy for
England and Wales, 1914.

From the tone of this report it is surmised that its successor
will be of somewhat different form and substance. Indeed, it
would appear to contain both its own obituary notice, and a
lettre d'e?ivoi of a new form of report to come.

It is thus with not a little feeling of regret that we peruse
its pages, knowing that it is for the last time we can linger
over its courteous and strictly accurate language, and absorb
something of the sincerity, the sense of responsibility, and
dignity which imbues the body whose work is there recorded.

The disappearance of the old Board of Commissioners and
its submergence in the newly created Board of Control is a
definite landmark in the history of the progress of psychiatry

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in this country; just as its appearance, in 1845, was the
harbinger of a period of progressive improvement in the care
and treatment of the insane, and which witnessed the triumph
of an enlightened humanity over the twin forces of superstition
and cruelty—a triumph largely due to the work of the Com¬
missioners as a body, but perhaps more so to the personal
influence exerted by individual members during their visita¬
tions throughout the country.

The Commissioners on their creation appear to have adopted
definite ideals, which were probably much in advance of the
popular thought of the times, such as the supremacy of medical
care and kindly treatment, the prevention of unnecessary and
unjust detention, the restriction of methods of restraint and
seclusion, the provision of suitable accommodation and the
exercise of all due economy in so doing, the affording of legal
protection to the insane as regards property, the improvement
of asylum administration and the status of the staff, etc. We
offer them our tribute of admiration for the consistent way
they have throughout “ stuck to their guns,” and acted up to
their ideals, in spite of the difficult conditions under which they
have worked. They have had a generous share of criticism and
opposition, but nevertheless have good reason to be proud of
their achievements, and both past and future generations owe
them a debt of gratitude.

The decease of the Commissioners in Lunacy is really more
of a re-incarnation, and not a death due to degeneration and
decay. They, amongst other influences, have been an active
agent in the growth of a volume of public opinion which held
that the time had come for the broadening of our conception
of those who ought, by reason of mental disability, to receive
the protection of the State for the good of the Commonwealth.
The spirit sustained by the humane work of the Commissioners
bore good fruit, a further instalment of the reply to the query,
“Am I my brother’s keeper?” was forthcoming,and the feeble¬
minded were to be gathered in, an enlargement of work out
of all proportion to the capacities of the public bodies, as then
constituted, in whose care were the mentally afflicted.

It was thought wise to create a new authority, hence the
birth of the Board of Control, and to incorporate in it the
Commissioners in Lunacy.

It has not been without some anxiety to those to whom the

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care of the insane has been entrusted that these changes have
occurred. The great matters for concern were : “ Would the
same spirit which had actuated the Commissioners in Lunacy
in their dealings with the insane continue in the same measure
to pervade the work of the new body in its more comprehensive
field of activity?” and “Would the interests of the insane
suffer from being not the only work of the new authority ? ”
Another anxiety was the kind of influence which would dominate
the policy of the new Board—medical, lay, legal, etc.

From the personnel of the newly created Board, we have good
reason to hope, if not to firmly believe, that all such and similar
questions will be answered satisfactorily, and that time will
show the wisdom of Parliament concentrating in one body
work very largely of the same nature, and that the great ideals
of the old Board of Commissioners will not only survive but
be rejuvenated, and flourish exceedingly in the new order of
things, strengthened and not weakened by contact with larger
activities, new aspirations, and recent developments of social
progress.

The coming into operation of the Mental Deficiency Act,

1913, on April 1st, 1914, is duly reported, together with a
brief account of the scope of the new Act, and the constitution,
powers, and duties of the new Board of Control.

Following this is a short, but succinct, history of the work of
the Commission established in 1845, down to its decease in

1914, which forms valuable reading. This entails a description
of the growth of lunacy and of asylum accommodation—one
being a necessary corollary of the other.

County and borough asylums, licensed houses, registered
hospitals, criminal asylums, institutions for idiots, naval and
military hospitals, are dealt with in various sections, forming a
valuable historical retrospect. It is most interesting when
studied in conjunction with the last Presidential Address.

It is often said that history repeats itself, and modern
suggestions may unconsciously be mere repetition of occurrences
in the past. We read that, at Guy’s Hospital, “in 1797
a special ‘ lunatic house ’ was built, and the hospital continued
to receive into these wards insane patients until 1859, when
the wards were devoted to other purposes, the few patients

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therein remaining being, by direction of the Governors, sent to
workhouses, a measure against which the Commissioners in
Lunacy protested.” Later occurs: “It will be noted that
some of these institutions for the insane were established in
connection with general hospitals and infirmaries, e.g., the
special wards at Guy’s Hospital, and the Royal Infirmary,
Manchester, and the ‘lunatic hospitals’ at Liverpool, North¬
ampton, and Oxford. Although this is of interest, as showing
the conception of insanity as a disease needing remedial
treatment has long prevailed, yet the early records show how
unenlightened, and, indeed, inhumane, such treatment often was.”

We are not very sure that the same, in a less degree, would
not happen now were the insane again handed over to medical
practitioners who are without special training. There are few
of us who have not been, from time to time, shocked at the
suggestions made for the treatment of the insane by individuals,
medical and otherwise, of well-known kindly dispositions.
Knowledge of the insane and their management is essential to
their proper and humane treatment, without which well-meant
kindness can readily and unwittingly become cruelty.

The statistics of the insane are analysed by the same
methods as in former years. No new or outstanding facts
are brought to light this year. We are always specially
interested in the ratio of the first admissions to the population.
In 1913, it was 4^99 per 10,000, or 0'26 below the average
rate (S' 15) during the past decade.

The Commissioners, following the practice of previous
years, again devote special attention to one particular aspect
of their work. This year the occurrence of syphilis in relation¬
ship to insanity, and also of general paralysis, is selected for
detailed consideration.

The whole value of the statistics regarding syphilis as an aetio-
logical factor in mental diseases depends upon the data they
are prepared from, especially as to what is regarded as evidence
of acquired syphilis. We know now quite definitely that
general paralysis is due to syphilis, but statistics regarding
syphilis and general paralysis by very competent observers have
varied enormously. We are not inclined to value very highly the
statistics from which the Commissioners obtain their informa¬
tion. Nevertheless, from the material at their disposal, the
Commissioners make some highly instructive deductions. Pro-

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bably nothing short of a Wassermanti test on each admission
would provide any reliable data. In this connection, some
work done at the Warren State Hospital is interesting (see
vol. lxi, p. 132). Excluding general paralysis, Is the propor¬
tion of syphilis any higher in the insane than in the general
population ? This would appear to be the starting point of
any inquiries regarding the influence of syphilis in the causa¬
tion of insanity.

The Commissioners are dealing with much more concrete
material when considering the incidence of general paralysis.
The disease averaged about 2'4 per cent, of the total number of
patients in residence in the county and borough asylums
during the last fifteen years. Of pauper patients, general
paralysis was diagnosed in about 7’5 per cent, of the admissions
during 1908-12. Excluding cases other than “first attack,”
the percentage was ii'9 males and 2’i females. The general
deductions to be drawn from their investigations are that the
incidence of general paralysis is greater in borough than county
asylums, and that, as a rule, it is greater in those county
asylums which receive patients from large industrial centres.
Low percentages are nearly always met with in purely agri¬
cultural districts. No less than 90 per cent, come under care
between twenty-five and fifty-four years of age, and 42 ”j per
cent, between thirty-five and forty-four. The average death-
rate in asylums from this disease during the years 1903-12,
calculated on the average number resident, has been 2^29 per
cent, males and o'6o per cent, females.

Attention is devoted to the difficulty experienced in obtaining
assistant medical officers. It is suggested that the improve¬
ment in the future prospects of those entering the service is
more important than a higher initial salary. Permission for
the senior and second to marry is advocated, also the pro¬
vision of suitable detached residences for married medical
officers within the grounds of the institution. All these sug¬
gestions are good, excepting that it hardly appears necessary
that the latter should actually be within the grounds of the
asylum. They should undoubtedly be within easy distance of
the building in case of emergency. Study leave is also advo¬
cated Regarding this, we think greater advantage might
first be taken under present conditions of the reasonably near
situation of some of the medical schools to the asylums.

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It is never possible in the pages of the Journal to comment
on every subject touched upon by the Commissioners in their
Annual Report. We have, however, sufficiently indicated that
the Sixty-eighth, and last, Report of the now deceased Board of
Commissioners in Lunacy, is in no way inferior in interest or
importance to its predecessors, but, on the contrary, is strongly
indicative that the Board of Control has absorbed a body of
men, fully alive to their grave responsibilities, and in good trim,
not only to continue the work which has engaged them in the
past, but to co-operate vigorously in the elucidation of those
larger problems which face the newly constructed and enlarged
authority.

Grants for Psychiatric Research.

At the last meeting of the Council of the Medico-Psycho¬
logical Association an application was made by the new
Research Committee of the Association that grants should be
made from its funds towards research work (on similar lines to
those adopted in the case of the British Medical Association).
The Council approved of the principle, and intimated their
willingness to receive applications, each of which would be
judged on its merits, and an award made accordingly.

The value of research work has up to this been greatly
under-estimated ; the view of its absolute necessity, if real pro¬
gress is to be achieved, has hardly been seriously entertained.
This is especially the case as regards psychiatry, and yet it is,
perhaps, this department of medicine where it is most urgently
needed. Some splendid work has been, and is being, accom¬
plished by voluntary effort, but neither the profession nor the
general public have any equitable right to appropriate to their
own advantage the fruits of the industry of others in which they
have taken no share. Every right-thinking person must, there¬
fore, regard with the utmost satisfaction the action of the
Council in sanctioning grants from the funds at their disposal
for this most important object.

Original investigators, pioneers in research, are rare. They
must be specially gifted with the faculty of imagination,
capable of limning out the problems best worth considering,
and of devising means and methods for their successful solution.
They must be endowed with keen powers of observation and,

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at the same time, ability to interpret what they observe : the
seeing eye and the understanding heart. But besides these
gifts, which are those in which they specially surpass the mass
of their fellows, they must pre-eminently possess those qualities
which the Prime Minister, in his eloquent appeal to Parliament
and to the nation for their support, material and moral, in the
most difficult military crisis which this country has ever had to
face, described as belonging to the “ spiritual ” side of our
national character : as “ ancient, inbred qualities of our race,
qualities of self-mastery, self-sacrifice, patience, tenacity, the
dominating sense of duty, unfailing faith, inflexible resolve.”
What language could better describe the principles which
animate the souls of those who are engaged in a different kind
of warfare—in the fight against our relentless enemies, disease
and death ; whose lives are spent in the endeavour to wrest
from Nature her secrets, and to discover the source and origin
of those malignant disorders which work havoc, and too often
irremediable disaster, in the delicate framework of the human
body; and not only in this, but in efforts, efforts which
happily have often been crowned with success, to find a
remedy against these insidious foes ?

We cannot for a moment suppose that our small band of
investigators are actuated by any mercenary motives. The
excellent work they have already achieved without any expec¬
tation of material compensation is enough to dispose of such
an assumption. As a class, there are probably few who are
less influenced by the auri sacra fames which is the main
incentive in many other departments of work. But everyone
likes to know that honest work will meet with appreciation.
And, nowadays, it is to be feared that the only appreciation
which carries weight, at any rate with the general public, is
that which is capable of being expressed in terms of hard cash.
But, apart from any considerations of this kind, it is both just
and fitting that work which is capable of benefiting humanity
to so great an extent should be adequately compensated, and
that every encouragement should be given to those who have
special aptitude for pursuits of this kind to prosecute their
studies under the assurance that their careers will not suffer
while they are employing their talents in adding to our practical
knowledge of disease, with, as a result, a diminution in the
suffering of their fellow-men. The funds of the Association

LXI. 1 8

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could hardly be employed for a more useful purpose, and the
action of the Council is sure to have the hearty approval of the
entire Association.

Part II.—Reviews.

Fifty-sixth Annual Report of the General Board oj Commissioners in
Lunacy for Scotland {being for the year 1913).

The first portion of the report gives the usual statistical information
in regard to lunacy in Scotland. On January 1st, 1914, there were in
Scotland, exclusive of insane persons maintained at home by their
natural guardians, 19,346 insane persons of whom the General Board
had official cognisance. Of these, 2,624 were maintained from private
sources, 16,660 by parochial rates, and 62 at the expense of the State.
Since January 1st, 1913, an increase of 158 had taken place. Of the
grand total given above, there were resident in the Criminal Lunatic
Department of Perth Prison 62 (an increase of 6 during the year), and
in training schools for imbecile children 602 (an increase of 22); and
these are classed as the non-registered lunatics. The registered lunatics
—those resident in asylums (royal, district, private, and parochial),
lunatic wards of poorhouses, and in private dwellings—were 18,682 in
number; and in regard to them the following changes had taken place
during the year 1913 : (1) There was a total increase of 130, due to an
increase in private patients by 27, and an increase of pauper patients
by 103. (2) The total increase of 130 arose from an increase in the

number in establishments by 208, and a decrease of the number in
private dwellings by 78. (3) The increased number of 208 in

establishments arose from an increase of 29 private patients, and an
increase of 179 pauper patients. Of pauper patients in establishments,
the average annual increase during the preceding five years was 199,
and,'therefore, the increase of 179 during the year 1913 has been less
than the average annual increase of that quinquenniad. During
the year 1913 decreases in the number of pauper lunatics occurred in
14 counties or urban areas, and increases in 20 counties or urban
areas. The proportion per 100,000 of general population is for private
lunatics 52, and for pauper lunatics 342, or a total of 394 for the two
classes together.

Patients in asylums and lunatic wards of poorhouses. —In arriving at
the number of persons admitted to these establishments, it is neces¬
sary to exclude the cases which mean merely a transfer from one
establishment to another, the number of these during the year being
371. With this correction made, the number of patients admitted to
establishments during 1913 was 3,682, (private 580, pauper 3,102).
This is an increase of 213 above the previous year, and is the highest
number of patients admitted in any single year to these establishments
for the insane in Scotland. The proportion of the admission rate per
100,000 of the general population was 77 - 8. The number of patients

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who had never previously been on the register, and who were ad¬
mitted for the first time to these establishments, was 2,806 (private 456,
pauper 2,350); and the proportion per 100,000 of the population was
59 - 2 (private 96, pauper 49-6). On the whole, with marked oscillations,
there has been a general tendency to increase, both in the total number
of cases received, and in the proportion of first admissions to the general
population. The number of patients discharged recovered during the
year was 1,421 (private 222, pauper 1,199), being an increase over the
preceding year of 24 private and 109 pauper cases. Though the re¬
coveries were thus more numerous in 1913 than in 1912, yet the
percentage of recoveries on admissions (exclusive of transfers) continues
to be distinctly lower (by 4 - 2 per cent!) than it was in the quinquenniad,
1900-4. The number of cases discharged unrecovered was 537
(private 144, pauper 393), the figures showing that there was an increase
of 8 in the private cases so discharged, but that the number of paupers so
discharged was the same as in the preceding year. The percentage of
cases discharged unrecovered, calculated on the number resident, was
62 for the private patients, but only 30 for the pauper patients. The
number of deaths during 1913 was : private 196, pauper 1,320, total
1,156, showing a decrease of 32 private, and an increase of 25 pauper
deaths on the corresponding figure for the year 1912. The proportion
per cent, of deaths calculated on the number resident was §‘4 for the
private, and 99 for the pauper cases, or for the two classes taken
together 97.

Voluntary patients. —Patients admitted to* establishments on the
voluntary system are not registered as lunatics, and are, therefore, not
included in the figures given above. The number of these received
during the year 1913 was 112 (which is 8 above the average annual
number admitted for the ten years, 1904-13); and the number resi¬
dent, January 1st, 19x4, was 148. The General Board “have for many
years been able to state that nothing had occurred to indicate any
difficulty or disadvantage traceable to the presence of this class of
patients in asylums ; and we continue to be of opinion that it is a
useful provision of the law which permits persons who desire to place
themselves under care in an asylum to do so in a way which is not
attended with troublesome or disagreeable formalities.”

Patients in private dwellings. —On January 1st, 1914, the number of
patients in private dwellings under the cognisance of the General Board
was 2,943 (private no, pauper 2,833). This shows a decrease
during the year 1913 of 2 private and 76 pauper cases. The decrease
is probably due to a combination of several causes, but may, it is hoped,
prove to be temporary only, as the system of private care is an important
part of the Scottish lunacy arrangements, and provides satisfactorily and
economically for a considerable proportion of the insane. The two
deputy-commissioners who are specially concerned in supervising these
cases both point out that there is little real difficulty in finding a
sufficient supply of suitable guardians for the patients.

Training schools for imbecile children. —There are at present in
Scotland two institutions which provide accommodation and specialised
training for mentally defective children—one at Baldovan (near
Dundee), and the other at Larbert. Both of them have done good

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work for many years, though their usefulness has been limited by lack
of funds; but the recent coming into force of the Mental Deficiency
Act will doubtless have the effect of increasing largely the demand for
accommodation for children of this class, and of enhancing the scope of
action of the training schools.

Expenditure for lunacy purposes .—Much detailed information is, as
usual, given in regard to expenditure. In the district asylums the
provision and upkeep of land and buildings is met by a special assess¬
ment in the lunacy districts, and for the year ending on May 15th, 1913,
the rate varied in different instances from £5 10s. 5 d. to £35 13J. 11 d.
per patient, the average being £16 is. 3 d. The conditions which lead
to the great variation in the rates in different districts are such as
amount of land provided, difference in cost of building in different
localities and at different times, and difference in the policies followed
as to the completeness with which the various requirements are provided,
whether fully at once, or gradually by successive additions. The
expenditure from parochial rates for the maintenance (that is, the
feeding, clothing, and management) of patients in district asylums does
not show the same degree of variation in different districts, and ranges
from £21 os. 8 d. to £32 or. 5 d., the average being (after deduction of
farm profits, etc.) £26 3*. 4 d. The patients in lunatic wards of poor-
houses and in private dwellings, being of a more chronic and less
troublesome kind, do not call for the same amount of expenditure; and
while the rate of maintenance for pauper lunatics in all asylums, and in
training schools for imbecile children, was on an average 1 s. 6d. daily, for
patients in lunatic wards of poorhouses it was is. 3d., and for patients
in private dwellings it was ir. o \d. The tables given in the report
show that for the maintenance of 19,139 pauper lunatics who were
under care for longer or shorter periods during the year in asylums,
lunatic wards of poorhouses, and private dwellings, and for other
expenses connected with them, a total sum of £432,534 was paid, of
which £346,422 was for maintenance in asylums (including institutions
for imbecile children), £19,351 was for maintenance in lunatic
wards of poorhouses, .£54,429 was for maintenance in private
dwellings, and .£12,332 was for certification, transport, and other
expenses. Of this expenditure, ,£23,378 was repaid by relatives and
others, and .£116,389 was contributed by the Government grant. The
net expenditure by Parish Councils on the maintenance of patients was
thus £292,767, which is £3,871 more than the expenditure of the
previous year. As, since 1892, the amount contributed by the State
(usually called the Government grant) has been a fixed sum, while the
number of patients among whom it is distributed has been rising, the
average amount paid per patient has been gradually falling, and for
the year ending May 15th, 1913, it was 2X. n d. per week, which is \d.
less than in the previous year.

Legislative and administrative changes .—The Mental Deficiency and
Lunacy (Scotland) Act was passed by Parliament in 1913, and modifies
and extends very largely the powers and duties of the General Board of
Commissioners. The main purpose of the Act is to make provision for
the care and management of mental defectives, and to place them (in
addition to the insane already provided for by former lunacy statutes)

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under the supervision of the General Board. The local administration
of this portion of the Act is shared in the different districts between the
School Boards, the Parish Councils, and the District Board of Lunacy,
the last-named being called in future the District Board of Control.
The Act also includes amendments of the lunacy statutes intended to
meet defects found by experience in the working of these statutes, and
to widen their provisions. These amendments are sketched shortly in
the report, and refer mainly to improvement of details in the ordinary
administration of the Acts, but bring up also some points of special
interest, of which the following may be mentioned: (i) A change in
the allocation of the maintenance expenditure for pauper lunatics, by
which it will, instead of being met wholly by the Parish Councils as in
former years, be divided equally between them and the District Boards
of Control; (2) for an established officer or servant in an asylum time
previously served in a parochial asylum or in the lunatic wards of a
poorhouse shall be counted for superannuation purposes ; and (3)
statutory power given for District Boards of Control to contribute
towards the support of any pathological laboratory having for its object
the investigation of the pathology of mental diseases.

In Scotland the Mental Deficiency and Lunacy Act did not come
into force until May 15th, 1914, and accordingly the effects of its
provisions, and the action resulting from them, do not fall within the
present report, but will have to be considered in detail in future years.
Under the Act the designation of the General Board is changed; it
becomes the General Board of Control for Scotland, and the report now
under notice is, therefore, the last to appear as being presented by the
General Board of Lunacy. The opportunity is therefore taken to
include in the report a review of lunacy administration in Scotland
since 1857, the year in which the General Board of Lunacy was
established. This review is very interesting and informative. Evidence
gathered by a Royal Commission, which sat from 1855 to 1857, showed
that the number of the insane in Scotland was then estimated at 7,403.
Of these 3,328 were more or less under the protection of the existing
law, but the majority, 4,075, were not under the cognisance or protec¬
tion of the law. At that time the seven royal or chartered asylums,
which had been founded and were in a great measure maintained by
the exertions and benevolence of private individuals, had been in
existence for a number of years, and these, and a few of the smaller
private asylums or licensed houses, provided for their inmates accom¬
modation and treatment of a satisfactory and even praiseworthy kind.
But there were no legislative enactments making it compulsory to
supply asylum accommodation for pauper patients, and many of the
insane were left in unlicensed poorhouses, in unlicensed private asylums,
and (most numerously of all) in private dwellings, where, in the absence
of proper supervision, their condition was of a very unsatisfactory and
objectionable kind, and exposed them to much suffering and privation.
Scotland was thus in the peculiar condition that, while on one side
private benevolence had done much for a portion of the insane, the
care of the great majority was most inefficient, through the non¬
existence of any public institutions or supervision for them, and called
urgently for reform. As a result of the report of the Royal Commission

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the Lunacy Act (Scotland) of 1S57 was passed, by which the General
Board of Lunacy was constituted, and charged with the general super¬
vision of the insane throughout tire country, and provision made for the
erection of public asylums in the different districts where required.
Each inspector of poor was now bound to intimate to the Board the
name and residence of every pauper lunatic within his parish, and in
this way the great majority of the insane were brought under the direct
cognisance of the Board. The Board further had the power to dispense
with the removal of any pauper lunatic to an asylum, and to allow the
parish authorities to provide for him under such conditions and regula¬
tions as might be laid down by the Board. At that time there were
nearly 4,000 insane persons resident in private houses, and, as the
asylum accommodation was insufficient to receive them, it was necessary
to leave a large number of them still under care in private dwellings,
after the necessary dispensation from removal to an asylum had been
obtained in the statutory way. As asylum accommodation was gradu¬
ally provided on a more extensive scale, the leading aim of the Board in
the early years of the work was naturally to remove from private houses
those patients whose mental condition or peculiarities made asylum
care necessary or preferable; and evidently it was considered that much
the larger number of the cases would thus be transferred to asylums,
while it was suggested that the remainder might be suitably provided
for by a scheme of cottage homes in the neighbourhood of each asylum,
and under the supervision of the asylum authorities. At the same time,
regulations were made for securing that the patients remaining in private
houses should receive suitable care and supervision. Experience, how¬
ever, gradually showed that it was not necessary to aggregate all the
insane in asylums, or even to have their cottage homes connected
immediately with an asylum, but that, under due regulations, a consider¬
able number of them could advantageously be provided for in ordinary
houses scattered throughout the country. In this way there grew up the
system of care in private dwellings, which continues to be an important
and distinctive feature in the lunacy administration of Scotland. At the
present time it provides for over 17 per cent, of the pauper lunatics on
the roll of the General Board. For a number of the cases asylum treat¬
ment has never been necessary, and these rd-main under private care
during the whole lime of being on the register. Others, after a period
of asylum care, have passed into a more manageable state, allowing of
removal to private houses, which helps to lessen the accumulation of
chronic cases in asylums, and it is to this procedure that the term
“ boarding out ” more strictly refers.

While the lunacy legislation of 1857 and subsequent years thus led
in Scotland to the development and organisation of the system of care
in private dwellings for a considerable number of the insane, its most
important effect was seen in another direction, in the providing of
public asylums throughout the country for those of the insane who
require care and treatment of a more specialised kind than can be got
in private dwellings. It has already been mentioned that in the royal
or chartered asylums Scotland had already several institutions doing
excellent work of this kind ; but their accommodation fell far short of the
requirements, and it was necessary to provide other institutions, which

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took the form of district and parochial ( ] ) asylums. Under the super¬
vision of the General Board, these have been gradually supplied as
circumstances required and allowed ; and thus all the districts of Scot¬
land have now public institutional accommodation to a larger or smaller
extent at their command for their rate-supported insane cases. During
their gradual growth changes of a very important kind have also taken
place in the administration of the asylums. The merely custodial
element, which was at first unduly, and perhaps unavoidably, promi¬
nent, has been replaced by arrangements directed to securing the
careful medical and scientific treatment of the mental and bodily con¬
ditions of the patients. The following points are mentioned and
discussed at some length in the report, as showing the progress made
in various directions, and how the improvements have been evolved :
(i) Extension of asylum lands; (2) abolition of airing courts; (3) the
open-door system, and liberty on parole ; (4) diminution in the use of
restraint and seclusion; (5) provision of hospital accommodation ; (6)
reform of night nursing; (7) nursing of male patients by female nurses ;
(8) the segregate or village type of asylum ; and (9) observation wards,
and pathological laboratories. These may be summed up as showing
that for acute insanity medical treatment of a scientific kind is pro¬
vided on the same lines as in a hospital for any other form of illness,
and that for all the insane (chronic and incurable as well as acute)
efforts are made to do away with unnecessary and hampering restric¬
tions, and to provide a mode of life as hygienic and favourable as
possible by supplying suitable surroundings, occupation, exercise, and
other interests, and by making their condition approach as nearly to
their home life in health as circumstances permit.

Credit for the important advances in lunacy work above referred to is
freely given in the Blue Book to the medical officers of asylums, who
have been responsible frequently for originating, and always for carrying
out, the new developments, and to the members of the public boards w hich
control local lunacy administration in Scotland, whose interest, humane
sympathies, and labour have secured the provisions of these conditions
for the benefit of insane patients. At the same time it is due to the
wise and far-seeing policy of the General Board that such progress has
been possible, and that Scotland has reached the high position it now
holds in regard to lunacy administration. That policy has been marked
by broad-mindedness, a desire to apply medical ideas to the treatment of
lunacy, a readiness to receive and encourage all suggestions for improve¬
ment in the care of the insane, and a sympathetic and cordial co opera¬
tion with the local officials charged with the work. Scotland has indeed
been fortunate in the personnel of the General Board during the fifty-six
years of its existence; and, in its enlarged constitution as the General
Board of Control, the supervision of the mentally deficient now
committed to its care will, without doubt, be as thorough and effective
as it has been in regard to the insane.

(') With one exception the parochial asylums have latterly all been constituted
as district asylums.

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EPITOME.

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Part III.—Epitome.

Progress of Psychiatry during 1914.

AMERICA.

By Dr. William McDonald, Junr.

From the advance that is taking place in so many directions these
days a few trends attract attention by their comparative newness.
Diagnostic tests such as the Wassermann, the Noguchi, the luetin, the
colloidal gold colour reaction of Lange, and the cellular analysis of the
cerebro spinal fluid are now being applied far and wide.

The value of these tests will soon be determined. Already it is almost
universally admitted that, although a positive response to such tests on
the blood serum is, with few exceptions, a reliable indication of syphilitic
disease, a negative response is untrustworthy where there is a question
of possible syphilitic involvement of the nervous system. Routine
examination of the cerebro spinal fluid, whenever there is suspicion
of syphilis of the nervous system, is now made in a large number
of hospitals.

The reports of these analyses favour the belief that an absolutely
normal fluid generally signifies escape of brain and spinal cord from
syphilitic injury, though a number of observers have found pupillary
involvement with a normal spinal fluid in subjects who gave a clear
history of syphilitic infection, and bore unquestionable syphilitic scars.
The spinal fluid may be normal while the blood serum reacts positively.
Morbid increase of cellular elements in the cerebro spinal fluid is seldom
lacking in cerebro-spinal syphilis, unless anti-syphilitic remedies have
been used diligently, but this increase of cells may be found in many
conditions other than syphilis.

It is a daily experience to find cerebro-spinal fluids which react
positively to some and negatively to other tests, and occasionally two
observers simultaneously testing one fluid find contradictory responses
to one form of test used by both examiners.

Lange’s colloidal gold test, judging from the reports, is, of all the tests
upon cerebro-spinal fluid, the most delicate. When the other tests are
positive, the gold test in reliable hands is seldom negative, and it may
alone give accurate evidence of syphilis when all other tests are negative,
but unfortunately it not infrequently responds positively when all other
tests are negative, and when all other evidence is against the assumption
of syphilitic infection.

The results of treatment of general paresis, tabes, and cerebro-spinal
syphilis with salvarsan, neosalvarsan, and with intra-spinal injections of
salvarsanised serum, are being watched with great interest. Reports
of these treatments are coming from all parts of the country. As yet
opinions are contradictory. Many observers are enthusiastic over the
results of their intra-spinal treatment, while others using the same
methods are pessimistic concerning their usefulness. There is also
much difference of opinion, even among those convinced of the efficacy

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of the treatment, as to the mode, technique, frequency, and number of
the injections.

It has not yet been determined whether the favourable results
obtained are to be attributed to the infinitesimal amount of arsenic
which finds its way into the subject’s cerebro-spinal fluid, or to the
creation of antibodies. Since the amount of recoverable arsenic in the
blood diminishes rapidly after the intravenous injection has been
completed, it follows that, if the curative quality of the serum depends
upon the arsenical content, the strength of this quality would lessen as
the interval between the injection of the salvarsan and the withdrawal
of the salvarsanised blood lengthened.

If, on the other hand, the beneficial effects are attributable to anti¬
bodies, a sufficient period after the injection of the salvarsan and before
the withdrawal of the blood must he allowed to elapse in order to
permit the antibodies to reach their highest possible development.
Thus it happens that there are those who, on theoretical grounds,
advocate a reduction of the prescribed one hour interval of the Swift-
Ellis method, and others who, on a different theoretical basis, insist
that at least twenty-four hours should elapse before the blood is with¬
drawn.

It has been pointed out by B. Sachs, I. Strauss, and D. J. Kaliski^ 1 )
on the authority of Prof. Benedict, of the Cornell Medical School, who
determined for them the quantity of arsenic present in the blood at
different intervals after the injection of salvarsan, that the spinal fluid
after simple intravenous injection of salvarsan contains a larger per cent.
of arsenic than is present in the diluted serum used for intraspinous
injection. These observers conclude that, whereas salvarsan combined
with mercury is the most effective remedy yet discovered for cerebral
and cerebro-spinal lues, the intraspinous method of treatment has no
advantage over the intravenous.

Several writers have stated that in their opinion the apparent
superiority of the results of intraspinous injection is due entirely to the
greater number of injections given by those who have used this method.
Between salvarsan and neosalvarsan it has not yet been determined
which offers the greater promise in these various methods.

To one who views these numerous studies with an unprejudiced
mind it seems apparent that the difference in opinion is in a large
measure due to the failure on the part of the observers to take into
account all of the related data. It is well known that general paresis,
as a rule, runs a more rapid course in extremely young adults than in
older victims, and it is necessary in all syphilitic infections to consider
the age, sex, colour, and condition of the subject previous to the
syphilitic infection, previous to the incidence of paretic signs, and
previous to the treatment, the amount, duration, and character of
previous treatment, and the virulence and direction of attack of the
infection.

That these newer modes of treating syphilitic diseases of the nervous
system have, on the whole, strengthened and widened the medical
resources for control of the disorders is beyond question. It has been
my good fortune to see, as a result of repeated injections of salvarsanised

f 1 ) Amer. Journ. Med. Sci., 1914, vol. cxlviii, p. 693.

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EPITOME.

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serum, the reincarnation of manhood in a paretic who, before the intro¬
duction of this form of treatment, would have been regarded as hope¬
lessly doomed to dementia ; I have also watched the steady downward
progress of other paretics treated as actively, and by the same method,
as was the one who was helped; and I have noted a temporary gain
under the same treatment by others who later went the way of the
classical paretic.

In time we shall understand the laws underlying such divergent
results.

No account of the progress of psychiatry in America would be com¬
plete without reference to recent efforts to obtain a better understanding
of the conditions underlying juvenile delinquency. Juvenile courts have
been established in many cities, and there is a genuine awakening to the
infinite good to be accomplished by doing away with the older stereo¬
typed police court methods of dealing with delinquents old and young
alike as a class, and by substituting a treatment planned according to
the particular needs of the individual. In this work magistrates are
co-operating with specialists in psychiatry, psychology, and sociology.
Chicago has established a system which offers an excellent example to
other municipalities.

Under the leadership of Wm. Healy, Director of the Psychopathic
Institute of the Juvenile Court of Chicago, a movement is under way
which gives promise of revolutionising criminology as related to both
old and young offenders. A paragraph from the Illinois Medical
fournal (October, 1914, p. 359) is worth quoting in the interest of the
“ better understanding ” which Mr. Healy is seeking to promote :

“With development of these better understandings many remedial
agencies have been set at work. In the Detention Home the w y ards of
the court profit by the daily attentions of a physician, a dentist, a corps
of teachers, an instructor in physical training, and resident nurses.
The court sends to the best specialists all cases of defective vision, and
the many other ailments which need attention. It obtains country
life for many of those who need it. It runs a definite employment
agency, which endeavours to place the individual at work for which he
is especially fitted. It aims to place in proper institutions those who
are afflicted. Above all, it endeavours to co-operate with relatives and
awaken them to the needs of their own kin. So it has come about that
in the sessions of this court one may hear considered the correlations
between defective vision and failure in school and in employment,
which, of course, lead directly to delinquency. One may hear discussed
the relationship of epilepsy to moral unreliability, of the effects of
various debilitating habits in producing mental instability or lethargy,
or the connection between mental defect and criminality. All these,
and many other things, should be considered by officers of a court, as
well as the more obvious effects of bad companionship, lack of parental
control, and other weaknesses in environmental conditions.”

There are indications on every hand of an awakening to the import¬
ance of attending to children sick in mind, not alone those w’hose
behaviour brings them into conflict with the law of the land, but any
who give signs of becoming aught else than normal citizens.

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Anxiety as to insanity in adults of the next generation may be justly
given up to the extent to which we can guarantee the mental health of
the children of to-day. L. Pierce Clark,( s ) under the title “ Psychopathic
Children : What New York City is Doing for Them,” has written a
paper pleading for “ more intensive study of child, and even infantile,
life.” He recommends the establishment in the public schools of all
large cities of a department “ for clinical study of the frank psychopathies
of school-children.”

Clark summarises a tentative scheme for examination of psychopathic
children as follows :

“ Name, Age, Father’s and Mother’s Name, Address.

The child’s main difficulties.

School record in normal classes.

Intellectual tests : Simon-Binet and its modifications.

Family history : Data obtained from parents by physician and social
worker.

Personal history : Chronologic physical development of the patient
from birth, made up of facts obtained by physician , social j worker , and
from parents.

Physical and neurologic examination.

Mental examination : Inquiries and observations regarding general
appearance, manner, conduct, etc. Mental development of infancy and
childhood. Personality study. Patient's own story in regard to his diffi¬
culties, and how he thinks they may best be set right. Social report on
environmental, social, and economic conditions.

Other facts concerning the child.

Summary of the case.

Treatment and correctional methods recommended.

Observation in ungraded class.

Results of re-examination.”

To find some measure whereby may be estimated the importance to
be ascribed respectively to inherited tendency, previous experience,
personality, and immediate stress as factors in the production of
insanity in the individual is the earnest endeavour of many American
psychiatrists. Effort in this direction may be seen not only in studies
concerning psychopathic children and juvenile deliquency, but also in
the broad and comprehensive methods lately advocated for the investiga¬
tion of mental disorders in adults.

August Hoch, Director of the Psychiatric Institute of the New York
State Hospitals, continuing his investigations ( 3 ) of the mental make-up
of persons who develop mental disease, has, with George S. Amsden,(*)
published another paper on the relation between personality and the
psychoses. The authors suggest, as a guide, a large number of ques¬
ts New York Afed. fourn., April 11th, 1914.

(*) Hoch, August, “The Constitutional Factors in the Dementia Praecox Group,’’
Rev. Neurol, and Psych., August, 1910.

( 4 ) Hoch, August, and Amsdeh, George S., “A Guide to the Descriptive Study
of the Personality, with Special Reference to the taking of Anamneses of Cases
with Psychoses,” State Hospital Bulletin (N. Y.), November, 1913.

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EPITOME.

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tions to be put to those from whom information is sought regarding that
“ period of the patient’s life in which compensation, so to speak, has not
yet started to break down, i.e., the so-called normal period of the lives of
such individuals, and not the actual mental disorder in the stricter sense.”

Under the headings of this guide are questions involving :

“(r) Traits relating essentially to the intelligence, the capacity for
acquiring knowledge, the judgment, etc.

(2) Traits relating essentially to the output of energy.

(3) Traits relating essentially to the subject’s estimate of himself.

(4) Adaptability toward the environment.

(a) The more striking traits which on their abnormal side interfere in
a rather general and striking way with contact with the environment.

(b) Traits ivhich in a more specific , but in a less obvious, way interfere
with contact with the environment.

(d) Traits which in normal proportions are useful qualities , but in
exaggerated form interfere with efficiency.

(e) Traits which show a tendency to active shaping of situations, or the
reverse.

(f) Traits showing the attitude towards reality.

(5) Mood.

(6) Instinctive demands, traits which are more or less clearly related
to the sexual instinct.

(a) Friendship.

(b) Attachment to members of the family.

(i) General.

(ii) Specific sexual demands.

(iii) General traits derived from sexual instinct , or reactions against its
assertion.

(7) General interests.

(8) Pathological traits.”

Investigations such as those mentioned above relative to delinquency
and mental disorder in children, and concerning the personality of
adults previous to the outbreak of their mental disorder, indicate the
desire of American psychiatrists to acquire a broad knowledge of the
fundamental factors of mental disorder. These researches contrast
favourably with the weird demonstrations of the pseudo scientific
methods of so-called psycho-analysis as preached by Freud, and so
voluminously exploited in the medical journals of recent years.
Admitting the good intent of Freud and his disciples in seeking the first
wayward tendency of the mind in its earliest sexual awakening, it must
ultimately be apparent that such efforts deal with but a limited number
of an infinite variety of experiences contributing to the formation of
mental and moral character.

Despite the suggestion of delicate subterfuge in a system of examina¬
tion which depends largely upon the analysis of time reactions in the
responses of the subject to most innocent appearing stimuli, the dis¬
regard of scientific precautions against error of interpretation, and the
eager acceptance of any and all reactions capable of being forced into

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the artificial scheme or dream of the investigator, are almost ludicrously
clumsy.

At the risk of being declared unprogressive, ultra-conservative, and
even stupidly unappreciative of the finer developments of psychologic
research, I have regularly contended in these yearly contributions, and
in other publications, that no possible advantage over a straight¬
forward common-sense approach to the problems of psychiatry could be
found in the chimerical experimentation used by many who are seeking
information;about subconsciousness. Among investigators who would
regard with scepticism the uncanny revelations of crystal gazers, or the
weird testimony of one who had been affected by the unnatural environ¬
ment of a spiritualistic stance, are those who pursue their questioning in
a darkened room, where the silence can only be broken by the subdued
voices of the examiner and the examined. In the effort to shut out all
distractions they are introducing the same element of strangeness
which, because of its incalculable emotional effect, destroys the
reliability of the testimony of the spiritualistic medium.

The part which the stop-watch plays in measuring the time elapsing
between question and answer has supplied an appearance of scientific
exactness to the reaction time examination for which the term psycho¬
analysis has been so widely appropriated. The use of an instrument of
precision, lending to the examination something of the dignity of
laboratory technique, sufficed to blind many earnest workers to the
untrustworthiness of the entire procedure.

Moreover, in America, as I have no doubt elsewhere, eager but not
sufficiently discriminative students have accepted without question the
dicta—false, despite their deceptive tone of logical directness—that
the readiest approach to subconsciousness is through subconscious
channels, and that errors of conscious activity resulting from morbid
repression of subconscious emotions and ideas can best be corrected by
elevating the repressed subconscious factors, and harmonizing them
with the higher conscious life, through direct appeal to the subcon¬
sciousness in hypnotic and hypnoidal states.

That the vastness of the nonsense of such arguments should
escape the recognition of many honest workers who have accepted
them is remarkable. It would have been as reasonable to insist that
Columbus could discover new realms only by forsaking ships, well
known in the old world, unknown in the new, and by climbing up one
moonbeam and down another to the promised land. It would be as
plausible to declare that the only mode of preventing the repetition of a
child’s outbreak in uncontrollable anger is that of first deliberately
inducing the repetition and then appealing to the child in anger.
According to such principles, the correction of insomnia could best be
accomplished by waiting until the sufferer slept and then awakening
him to explain the error.

Fortunately, common-sense may always be depended upon to correct
ultimately the temporary erraticisms of scientific endeavour, and it is
highly satisfactory to find, in reviewing American psychiatric literature
of the year 1914, that, as compared with the years immediately preceding,
the exploitation of the flimsy theories of so-called psycho-analysis has
largely given place to the reports of more sober-minded investigations.

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FRANCE.

By Dr. Ren£ Semelaicne.

During the last year, scientific activity seemed to be suspended by
the war; the societies devoted to the study of mental diseases could not
meet for want of members, and the publication of specialist journals was
temporarily postponed. It is not yet the proper time for examining the
psychiatrical consequences of the present events, and such a study will
be more pertinently carried on subsequently to the conclusion of hos¬
tilities. So an epitome of French psychiatry only covers a period of
seven months, from the beginning of January to the end of July.

A new Lunacy Act, voted in 1907 by the Chamber of Deputies, was
considered at great length by a Committee of the Senate, and reported
by M. Strauss ; the debate opened at the end of 1913. According to it
the reception of any alleged insane person in a public or private esta¬
blishment is only provisional, and has to be submitted within six months
to the judicial authority. A discussion arose about the use of the
words “ mental alienation ” and “ mental affection.” In reality the Bill
was entitled as concerning alii ties, while Part I provided that help and
proper care should obligatorily be given to any patient suffering an
affection mentale. So the debate was postponed pending fuller informa¬
tion, and the Government decided to take the opinion of the following
societies: Academic de Midecine , Sociiti clinique de Midecine mentale ,
Societi de Mid;cine ligale, Sociiti Midico-Psychologique, Sociiti de Neuro¬
logic, Sociiti de Psychiatric. The answers were approximately the same,
i. e. that the expression mental affection includes any person suffering
from mental disorder; amongst such affections some merely require
help and care, but some others necessitate legal intervention, and in
their case the term mental alienation is properly applicable. Besides
the Sociiti Midico-Psychologique conclusively opined that the law of
1838 specifically providing for legal action, and safe-guarding the
liberty of the individual, seemed to be quite sufficient; but in order to
protect more efficiently the community it might be expedient to add
some judicial rules concerning criminal lunatics.

The committee’s reporter, anxious to obtain a prompt vote for the
lunacy law, had quoted public opinion and the apprehension of arbitrary
detentions. Dr. Gilbert Ballet, Professor of Psychiatry in the Faculty
of Medicine of Paris, at a meeting of the Academy of Medicine, defied
anyone to give a genuine case of such a detention. Subsequently to
the meeting, four cases of pretended arbitrary detention were submitted
to him. The first case was that of a melancholic patient, who secondarily
developed ideas of persecution, with refusal of food and acts of violence,
and was placed in a private asylum and artificially fed. A journal had
violently protested. In the second case the patient was the subject of
intermittent attacks of mania, which during some years had not been
very violent, so his wife took patient out in spite of a continuance of the
malady ; but he became more excited, had megalomaniac ideas, provoked
a violent scene on a railway, and was confined in a maison de satiti.
Improved by appropriate treatment, and restored to liberty, he was
protesting against his detention. A third person wrote : “ Three ruffians

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named Gamier (the scoundrel died since that time), Legras, and Magnan
are pleased to comply with the wishes of the grossly vicious French
police, and facilitate those monstrous acts of cowardice.” Another letter
began as follows: “ I suffered three confinements in a lunatic asylum,
because I asserted that I was a Bourbon, son of the Count of Chambord
and of the Duchess of Alen§on, with evidence in support.” The mental
disturbance of such people seems to be clearly apparent to anyone
possessed of common sense, but in any case of confinement in an asylum
the opponents generally consider their own interest in preference to the
benefit of the patient, and some journals eagerly accept every scandalous
report. Public opinion sometimes is right and sometimes wrong, and in
a scientific discussion one has not to consider such a matter. In a
meeting of the Academy of Medicine Dr. Gilbert Ballet proclaimed
that, even if public opinion was wrongfully becoming excited by a
chimerical case, the members of the Society ought not to be troubled by
that fact ; they had not to look at an electoral district as members of
Parliament, but only to give heed to the truth, and the benefit of the
patients.

The Lunacy Act, 1838, so violently and unjustly censured by incom¬
petent people, was suggested by Esquirol and Ferrus. Since that time
medical science has progressed, and many ideas have had to be modi¬
fied in order that the law might be improved, but it does not seem
necessary to radically reconstitute it merely in order to please some
politicians, and without any real benefit to patients. When one talks about
arbitrary detentions, he generally means to accuse the private licensed
houses where wealthy people are usually boarded. What are the actual
legal guarantees in such houses ? When a relative wishes a patient to
be received, he must present a petition, a medical certificate, and a
paper identifying the alleged insane patient. The superintendent has
to send, within twenty-four hours of the reception, a certificate to the
Prefect of Police in Paris, or to the Prefect of the Department in the
other parts of France. He sends also a notice to the Procureur de
la Republique. A medical inspector is directed to visit the alleged
insane person. A fortnight after the reception the superintendent
must send a new certificate. In Paris we receive as visitors : twice a
year a medical inspector, every quarter of a year the Substitut du
Procureur de la Rtfpubllque, a magistrate delegated by the President of
the Civil Tribunal of the Seine, and the Juge de Paix ; on the whole,
fourteen regular visits a year (I do not include Inspectors of hygiene
and buildings). Besides, every time a patient sends to the Prefect of
Police, or to the Procureur de la Rlpublique, a petition protesting
against his detention, a medical inspector is directed to visit him, and
has to present a report of the case. If anyone presents a protest
against the confinement of an alleged insane person, an inquiry is
ordered. So I am convinced that individual liberty is amply guaranteed.

The provision of the new Bill transferring the powers of detention to
judicial authority does not seem to secure an appreciable benefit to the
alleged insane person. A judgment against anyone appears as a
sentence. Besides, the magistrates, not having expert knowledge,
would ground their decision on a medical investigation. Consequently,
the new system might not be beneficial to anyone, excepting to the

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superintendent of the asylum, who could oppose a judiciary sentence to
the claims, and deny any responsibility for the detention of a patient, or
at least assume a limited responsibility. But in such questions we must
only keep in view the benefit of the patient, and not our own interest.

The expression alitne is not generally taken in a good sense by the
public, nor the terms previously used : fou and insensi. Nevertheless,
such expression is most ancient, since it dates from Asclepiades, a good
rhetorician turned a celebrated physician, who proclaimed, according to
Caelius Aurelianus, that alienatio est passio in sensilnts. Numerous
among the relatives of the insane are those who will not admit that
their patient is an alihtt, and they look quite satisfied if one answers
that it is not the case, and that he is suffering from a psychosis. Such
public repulsion with regard to the expression ali/w! had induced the
committee of the Senate to substitute the term, “ patient suffering from
an affection mentale .” But one cannot please everybody.

It is said that Asclepiades used to prescribe drinking, and even
inebriety, as a general treatment of insanity. Fortunately such a
therapeutic measure is no more in vogue. An energetic struggle has
been recently initiated against alcoholism, which fills the public asylums,
and has proved to be a most powerful cause of mental and physical
degeneration. Till now the distillers of alcohol and the tavern-
keepers, who have great influence over political elections, had suc¬
ceeded in opposing reform. So the Government, using the authority
conceded by the state of siege, prohibited by a decree the sale of
absinthe. But such a decree was good for the time of war only, and a
law became necessary. A Bill prohibiting fabrication, sale, and export
of absinthe has been voted by the Chamber of Deputies, and favourably
considered by a committee of the Senate. Another Bill on the regulating
and limitation of taverns is now being debated. Let us hope that,
in spite of powerful and selfish opposition, alcoholism will be definitely
mastered, and so the holy war will afford a complete deliverance.

Epitome of Current Literature.

i. Pathology of Insanity.

Functions and Structure of the Male Sexual Glands in Mental Diseases
\Ricerchc sulla fungione e sulla struttura dclle ghiandole sessua/i
maschili nelle malattie mentali\. (Rivista Sperimentale di Freniatria.
Jan ., 1914.) Todde.

This elaborate article maybe adequately presented to English readers
if the conclusions arrived at by the author are given :

(1) The volume and weight of the testicles in the various forms of
mental disease, compared with those of people who have died from
accident or ordinary illness, are very often more or less diminished.
Such diminution is constant, and is most marked in congenital mental
deficiency.

(2) In the various groups of mental disease, independently of age,

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the structure and function of the sexual organ appear much more
frequently, and more seriously, altered than in the sane.

(a) The lesions which are most important, constant, and sufficiently
distinct are met with in idiocy and imbecility. These lesions are
characterised by complete arrest of the process of spermatogenesis,
involving changes in the spermatoform and interstitial structures in the
epididymis and seminiferal canals, and an augmentation of the inter-
canalicular tissue. Not infrequently there is an absolute arrest of the
evolution of the organ.

(1 b) In dementia prtecox the functional disturbances and changes of
structure affect more especially the seminal gland. The changes found
are diverse. In some there is a quantitative alteration of the so-called
“ filial ” cells, and consequently there is a simple diminution of function ;
in the majority of cases, however, there is a true cell degeneration with
a complete absence of spermatozoa, or there may be an atrophy of the
seminiferous canals with total or partial disappearance of the epithelial
elements, accompanied by hyperplasia of the intertubular tissue.

(c) In paralytic dements there is usually an arrest of function. This
is accompanied by atrophy of the gland, with some inter-canalicular
sclerosis. The epididymis also takes part in this change.

(d) In secondary or consecutive dementia there are prevalent signs of
hypo-function of the testicles.

(e) In senile dementia, independently of the co-efficient of age, the
function of the sexual gland is usually more or less diminished.
Frequently function is completely abolished, and is then accompanied
by atrophy of the organ.

(/) In those forms of insanity which owe their origin to alcohol, the
function of the sexual gland is usually more or less at rest: though as
a rule diminished, it is rarely altogether arrested. The more marked
alterations are found in cases dying of hepatic cirrhosis.

(g) In pellagrous psychoses we find more marked signs of hypo-func¬
tionalisation, especially of the seminal gland. There are rarely serious
structural phenomena, and when they exist they are generally in direct
proportion to the duration and intensity of the psychosis.

(h) In maniacal-depressive cases occasionally the functional activity
of the entire organ is completely, or almost completely, abolished. In
the majority of cases a glandular atrophy is found.

Finally, the functional activity and structural lesions of the sexual
glands in the insane have no connection either with age or with the
cause of death. The alterations and lesions seem, on the contrary, to
be in direct connection with the gravity and duration of the mental
disease.

2. Clinical Psychiatry.

Paralysis from Phosphate of Creosote \Le Paralise da Fosfxto Creasoto].
(Revista Sferimentale di Fretiiatria, March, 1914.) Bertola?ii.

Phosphate of creosote is used medicinally under the name of Fosoto
in Germany. The case described was that of a man, ret. 2S, who took
the drug for chest trouble. In all forty grammes, at a rate of three
LX I. 19

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grammes a day, were taken. The medicine was then discontinued, and
after ten days symptoms of polyneuritis began to develop. In the
extremities subjective disturbances of sensibility were marked. These
painful impressions were worse on movement or on pressure over the
nerve trunks, but disappeared when the limbs were at rest. In from one
to five days symptoms of loss of power made themselves manifest. In
order of time the muscles of the leg were first affected, but the arms and
hands were later involved, though not as severely as in the case of the
lower extremities. Objective disturbances of the senses to touch, heat,
and pain were slight, but followed the topographical distribution of the
nerve trunks. These signs were followed by flaccidity of the muscles
involved, which degenerated and to some extent atrophied. The skin
became marbled in appearance, and desquamation took place.

The patient’s condition improved at the end of four months, and a
cure, though partial, was established at the end of a year.

v Colin McDowall.

3. Asylum Reports.

Some English County and Borough Asylums.

Cardiff City. —Dr. Goodall, as usual, furnishes particulars of the
effect of alcohol as a factor in the aitiology of his direct admissions.
Of the 105 cases analysed in which a history was given, fifty showed
heredity of some kind, alone or with exciting (principal ?) cause. Of
these, five had drink assigned as an exciting cause, and seventeen had
alcoholic heredity. Among the fifty-five in which no heredity was ascer¬
tained alcohol was assigned as an exciting factor in sixteen. Assuming
that the oiiginal assignment of aetiology was both exhaustive and
accurate, some light is thrown on the comparative prevalence of alcohol
as cause or symptom of insanity. In fifty cases with a taint of heredity
alcohol appears as an exciting cause in five only, whereas, with no such
taint, it appears in sixteen out of fifty-five.

The research work detailed naturally forms the most interesting part
of the report, and we have no hesitation in exercising a liberal use of
the scissors.

Investigations by Drs. Scholberg and Goodall. — Dr. Scholberg and I have carried
out research in collaboration, of which the following is a brief account. Firstly, in
respect to the Wassermann test; we communicated our results up to date with the
method of complement-deviation at the recent International Congress of Medicine,
London. Our main conclusions were as follows :

(1) We are unable to agree with those who state that with o - 2 c.c. (the usual
amount) of amboceptor fluid, a positive Wassermann is obtained in practically
100 per cent, of cases of dementia paralytica. This may he true of cases in an
early stage of the disease, or of those running a rapid course, although extremely
little authentic information is available on the point. Our experience shows that
in cases of long standing, such as those we worked with, and including several in
which the disease was progressing very slowly, or in which states of partial remis¬
sion or quiescence obtained, and in which only complete absence of hajmolysis was
recorded as a positive result, no more than 56 4 per cent, of the cases gave a positive
reaction in the serum, and 30'8 per cent, in the c.s.f. [Cases of retarded hemo¬
lysis are very numerous, resp. 18 per cent, and 20'5 per cent.] [See observation at
close.]

(2) The complement-binding substance is more active (stronger) in secondary

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than in tertiary syphilis, and in tertiary syphilis than in general paralysis.
(Wassermann—with 0'2 c.cm. amboceptor 1 in 10, respectively in 100 per cent.,
^3'4 P er cent., and 58 per cent.)

(3) Conclusion No. 4 of our previous paper (which is the conclusion reached by
the consensus of opinion), via.: that a positive reaction in serum or c.s.f. occurs
very rarely in cases of insanity other than dementia paralytica, if known cases of
syphilis are excluded, and the test be repeated, is confirmed by these further
observations.

(4) By increasing the amount of amboceptor used up to o '6 c.cm., positive
results in a series of cases of dementia paralytica were obtained in 36 per cent, in
the serum, and 48‘6 per cent, in the c.s.f., cases which gave negative or merely
retarded results with 0’2 c.cm. If our table of positive results in dementia para¬
lytica, composed of cases in which 0'2 c.cm. amboceptor was used, be corrected in
the light of this information, the percentage of positive results is raised in the
serum from 56 4 to 72, and in the c.s.f. from 30 8 to 64'5-

(5) The positive results in other mental disorders (Non-G.P.I.) were increased
by taking o '6 c.cm. amboceptor instead of 0'2 c.cm in the serum and c.s.f.,
respectively, by 5 to 6 per cent, and 7 per cent.

(6) Conclusion No. 8 of our former paper is confirmed, via. : that the reaction
may vary in serum and c.s.f. at different periods of the disease in a given case
without clinical change. A typical reaction also occurs in both fluids in pro¬
nounced and advanced cases.

(7) In some cases of general paralysis a positive Wassermann reaction is not
obtained until between 0'2 and and o't c.cm. of pure cerebro-spinal fluid is taken.
But 1 c.cm. is the amount required in some cases of cerebro-spinal lues, a point of
resemblance between these conditions which bears out the difficulty, and even
impossibility, of clinical diagnosis between them, and of histological differentiation
in atypical or long-lasting cases.

(8) The reaction is often negative or incomplete in remission, but it may be
positive.

The Nonne-Apelt reaction during remission is variable, and cannot be correlated
with that state, but is oftener positive than is the Wassermann test.

(9) The Nonne-Apelt test is positive in a higher percentage of cases of known
dementia paralytica than the Wassermann in the c.s.f. It is found more con¬
sistently throughout the disease than is the Wassermann. Wassermann is less
frequently positive in non-general paralytics, hence rather more reliable in
diagnosis.

(10) As regards the increase of cells in the cerebro-spinal fluid in dementia
paralytica ; as a test in actual cases of the disease, this seems about as constant
and reliable as the protein test, and therefore is more frequently positive than the
Wassermann; but, as a means of diagnosis, less dependable than either. No
correlation was found between number of cells and severity of disease.

(11) There seems to be no need, or but occasional need, to perform the
Wassermann test for the diagnosis of dementia paralytica. In psychiatric
practice, a positive protein test, a positive nitrogen test (Stanford), and pleocytosis
of the cerebro-spinal fluid constitute evidence of dementia paralytica. Exception
need be made only for those cases in which the diagnosis has to be made from
senile mania (G.P.I. sometimes occurs after 60 and undoubted cases have been
described at even 70) and from cerebro-spinal lues. In the former Wassermann
would be negative in all strengths of c.s.f., in the latter it would be negative
usually with 0'2 c.cm. of 1 in 10. But it is frequently negative with this
amount in dementia paralytica also.

Since the above results were communicated, Wassermann and Lange ( Berl.
Klin. Woch., 16, March 16th, 1914) have shown that the lymphocytes are the
source of the Wassermann reaction in the cerebro-spinal fluid, the centrifugalisa-
tion of this fluid in our cases, with the use of the supernatant fluid, will therefore,
largely account for our low percentage of positive results. The importance of
stating whether or not the fluid has been centrifugalised is therefore enhanced.

The employment of thyroid gland in large doses (40 to 60 grains a day) in
certain cases of an " anergic ” type, speaking generally, has given satisfactory
results, and I find that when the same substance, in the same large doses, is given
to epileptics, who are kept supine during the treatment, but on their usual diet, the

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published during the year (Zeitschrift fur physiologische Chemie, 1914, 86, 219).
Since that publication a large number of other cases has been examined, with
results entirely confirmatory of those recorded in the paper, so that it may fairly
be claimed that this, the first quantitative chemical method for diagnosis in insanity,
has a real diagnostic value, and it is now in use in this hospital for this purpose.
The differentiation of cases of ordinary mania from cases of general paralysis
showing maniacal symptoms is specially marked.

As a deduction from results obtained in this nitrogen estimation, I have recently
been able to devise an extremely simple and rapid test for the most important of
the nitrogenous constituents of cerebro-spinal fluid, which appear almost solely in
general paralysis. The test, of which an account will be published shortly, can
probably be made the basis of a method for the micro-quantitative estimation of
these constituents.

By methods similar to those already mentioned in this Report, it has been proved
that fresh cerebro-spinal fluid contains practically no ammonia (less than one
hundredth of a milligram per cubic centimetre), even in general paralysis cerebro¬
spinal fluid probably contains also no phosphorus.

In enlarging on the gratifying results of the Conference of Asylum
Authorities, which was due, we believe, mostly to the initiative of
Cardiff, Dr. Goodall issues a note of warning against the placing of any
portion of the grant now made for research in the hands of any but the
most competent worker. Chance connection with a mental hospital
should not be considered to be a qualification. We venture to think, too,
that grants should be chiefly given where there already exists sufficient
machinery for carrying on research work.

Both the Committee and Dr. Goodall refer, with grateful apprecia¬
tion, to the honour done to the Hospital by the special visit of the
Home Secretary, in whom much interest was aroused by what he saw.
This visit, besides being gratifying to Cardiff, must prove to be of
value to psychiatry in general. It will be remembered that Mr. McKenna
exerted all his power to pass the Mental Deficiency Act through
Parliament in the face of most strenuous opposition. His interest was
intense, not only in getting the Bill through, but in passing such an Act
as would do much good to the object sought. Having thus acquired
an interested knowledge, he may be looked to to further many of the
questions which call for serious attention. It surely is a great gain to
have a friend of our work inside the Cabinet, who can possibly persuade
the Chancellor to open his hand further than he has already done in
making the annual grant of ^1,500 for research. Another honour in
the year consisted in the choice of Cardiff by the International Congress
for a visit. Appreciative accounts were published in French and
German medical papers. In congratulating the Committee and Dr.
Goodall on these events, we feel bound to say that the honour is
thoroughly deserved. Psychiatric progress, both in medical and lay
hands, is persistent and most strenuous.

Cumberland and Westmorland Asylum .—Much thought is given to
reduce the cost of maintenance, and a table recording the annual cost
of a patient to the ratepayers is given, commencing from 1862. In
that year it was 111. ; the present year it is 9*. id. The cost of pro¬
visions has gradually, year by year, fallen, until now it is 2 s. nd., while
the salaries have irregularly risen to their present maximum of 2 s. 9 d.
At the same time we note that the salary of the Senior Assistant

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Medical Officer is, after eight years’ service, only ^225. Nurses
commence at £19.

Dr. Farquharson, in his remarks, says :

“ Beyond one case of colitis in the early part of the year, which terminated
fatally, there has been no epidemic or zymotic disease amongst the patients.
During the greater part of the year the infirmary wards, male and female, have
been filled with cases bedridden from age or disease. The open-air treatment of
these cases on the verandahs appears to have a remarkable effect in prolonging
life, many of them show little sign of vitality, yet they survive in a wonderful
way. At the end of the year there were in all eighty-three patients being treated
in bed, but this number also includes recent cases of mental disease, for whom the
open-air treatment in bed is equally beneficial. General paralysis of the insane is not
as common in these counties as in many other parts of England, but last year there
was an unusually large number of patients admitted suffering from this disease.
At the end of the year there were in residence fifty-two patients over seventy years
of age. Apart from the aged and bedridden cases, the general health of the
asylum population has been good throughout the year.”

We note the complete absence of Table D. This is not the only
annual report in which this want is noticeable, and we regret the
fact, as of all tables we think that this one is, perhaps, the most useful
scientifically, especially so in this asylum, where this year every patient
who died was the subject of a post-mortem examination.

Derby Mental Hospital. —Dr. McPhail says :

“ The admissions included six epileptics, six congenital imbeciles, seven general
paralytics, and five cases of senility. In addition, ten others have been of unsound
mind for over a year, and were therefore practically incurable and unlikely to
benefit by treatment. Thus, in at least 44 per cent, of the whole there was from
the first practically no prospect of recovery. There were fewer of the adolescent
class than usual among the admissions. A noteworthy feature was that recent
cases of a maniacal type and of a melancholic type came to exactly the same figure,
while an equal number of recoveries was obtained from exalted mental types as
from cases of mental depression.

“ There is little fresh to record or comment upon with regard to causation. The
Etiological Table (7) has been compiled as accurately as possible, taking into
account the difficulty of obtaining reliable information about the receptions.
Dealing as we do with a limited and comparatively small area, we have the advan¬
tage of knowing something about the relatives of many of the patients admitted.
For example, in the last twenty-five years I have twice had four generations of
patients under my care. But, until we are able to have detailed investigation by a
competent medical authority into the possible hereditary, acquired, and environ¬
mental causes of the insanity in each case admitted, we shall always have difficulty
in obtaining verified facts regarding the early stages of mental disease, which
might suggest measures of prevention.”

Dorset County Asylum.— Dr. McDonald, in his remarks on the
setiological causes operating during the year, says :

" Among the various causes as tabulated in several of the statistical tables there
does not appear to be any lessening of the widespread consequences of a predis¬
position to mental or nervous diseases. In quite a number of the cases admitted
during 1913 not only had there been instances of mental trouble in the family
stock, but the history showed associated factors such as epilepsy, tubercle, and
other equally potent complications. The simple, uncomplicated case is encouraging
and hopeful, but when you recognise the epileptic parent visiting the congenital
epileptic son or daughter, or the mother, who had formerly been a patient here,
visiting her eldest daughter, a bright, healthy-looking girl, the subject of adolescent
mania, then, indeed, are the results and ravages of a tainted stock made manifest

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beyond dispute. The idea that in a general way more discrimination is being
exercised is not borne out by the facts at one’s command. More often than not
the future is disregarded, if not absolutely ignored, and the truth of this is only
known when such painful examples as just mentioned are brought to light.”

We would congratulate the County in having a record of only two
males whose insanity was chiefly due to excess of drinking, and one
woman for whose mental breakdown a similar cause was partially
accountable.

Glamorgan Cou?ity Asylum .—We note the following remarks by the
Medical Superintendent, Dr. Finlay, on the nursing examinations :

“ For the Medico-Psychological Nursing Examinations twenty-eight candidates
entered, eight being attendants and twenty nurses. Of the former, five were
junior and three senior, and all were successful, two of the seniors passing with
distinction ; of the latter fifteen were junior of whom six passed, and five senior of
whom two passed. Considering the high standard of efficiency now required by
the examiners the comparatively large number of failures among the nurses is not
altogether surprising, and, as was pointed out last year, a very considerable
proportion of the resignations can be attributed thereto.”

We are sorry to think that the old adage of “Try, try again” is losing
its force in Wales, but we congratulate the two attendants who passed
with distinction. At the same time, we think it a pity that the nursing
examination should be blamed as a means of driving women from an
occupation. The average of 40 per cent. (2 out of 5) surely is not a
very unsatisfactory pass list. In another Welsh asylum, which shall be
nameless, for the same preliminary examination, three men sat and one
came down, nine women entered and seven were successful. From what
we know of the Welsh people we should never judge them to be dull,
or, as is suggested, of lacking in pluck.

Hertfordshire County Asylum .—Several interesting details are to be
noticed during the past year. Buildings are in course of erection for
the accommodation of a hundred female patients. The plans have been
approved for an attached block, the ground floor of which is designed
as an infirmary. In addition, a nurses’ home is to be built. The total
cost, excluding ^2,000 for furnishing, will be ^18,240. The Com¬
mittee have also bought ninety-seven ac